NM| Effective July 1, 2025, New Mexico Senate Bill 39 amends the Prior Authorization Act to prohibit prior authorization and step therapy for FDA-approved drugs (including off-label use) used to treat autoimmune disorders, cancer, substance use disorders, and rare diseases/conditions.
Key requirements include:
- Prior Authorization & Step Therapy Removed: Health insurers may not require prior authorization or step therapy for FDA-approved medications (including off-label uses) for specified conditions, except when a biosimilar, interchangeable biologic, or generic is available.
- Definition Updates: The law clarifies and expands definitions for “prior authorization,” “off-label” use, and “rare disease or condition” (affecting fewer than 200,000 people in the U.S.).
- Medical Necessity Determinations: Determinations must be made by a healthcare professional from the same or similar specialty; standard reviews must be completed in 7 days and emergencies within 24 hours, or the request is automatically approved.
- Notification & Forms: Insurers must update forms and procedures, provide prompt notification to covered persons, and ensure internal compliance systems, with materials reflecting these changes for both members and providers.
- Applicability: These requirements apply to fully insured plans issued or renewed on or after July 1, 2025, and non-formulary exceptions are to be reviewed simultaneously with medical necessity determinations.
