Great news – New Mexico has step therapy protections.
This law (NM Stat § 13-7-18 [2024] and Section 59A-22B-8 NMSA 1978) requires insurers to grant an exception if a healthcare provider demonstrates any of the following:
- the drug an insurer wants a patient to take is likely to cause an adverse reaction;
- the drug an insurer wants a patient to take is expected to be ineffective;
- a patient has tried and failed the drug before;
- the drug is not in their best interest.
A healthcare provider can request an exception on behalf of a patient, if they match any of the above criteria.
The insurer must respond within 72 hours indicating whether the step therapy exception request has been approved, denied, or they require more information. In emergency cases, the insurer must respond within 24 hours. If they do not provide a response within the timeline, the exception request shall be deemed approved.
Step therapy is prohibited for 1) drugs treating autoimmune conditions except in cases in which a biosimilar, interchangeable biologic or generic version is available, or 2) an off-label medication that is prescribed for the treatment of a rare disease or condition (affecting less than 200,000 people in the US).
Protections in New Mexico include Medicaid.
If a patient’s exception has been denied, a healthcare provider has the right to appeal. Instructions for filing an appeal will be sent to the provider who made the exception request. Reference the above criteria in your appeal.
If you believe an insurance company has failed to comply with NM Stat § 13-7-18 (2024) and/or Section 59A-22B-8 NMSA 1978, you can file a complaint with New Mexico’s Department of Insurance.
