Prescription drug Prior Authorization protocols. After January 1, 2014, a health care plan shall accept the uniform Prior Authorization form developed pursuant to Sections 2 [59A-2-9.8 NMSA 1978] and 3 [61-11-6.2 NMSA 1978] of this 2013 act as sufficient to request Prior Authorization for prescription drug benefits. No later than twenty-four months after the adoption of national standards for electronic prior authorization, a health insurer shall exchange prior authorization requests with providers who have e-prescribing capability. If a health care plan fails to use or accept the uniform Prior Authorization form or fails to respond within three business days upon receipt of a uniform Prior Authorization form, the Prior Authorization request shall be deemed to have been granted. As used in this section, "health care plan" means a nonprofit corporation authorized by the superintendent to enter into contracts with subscribers and to make health care expense payments but does not include: A person that only issues a limited-benefit policy intended to supplement major medical coverage, including Medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income; A physician or a physician group to which a health care plan has delegated financial risk for prescription drugs and that does not use a Prior Authorization process for prescription drugs; or A health care plan or its affiliated providers, if the health care plan owns and operates its pharmacies and does not use a Prior Authorization process.
Prescription drug Prior Authorization protocols. After January 1, 2014, a health care plan shall accept the uniform prior authorization form developed pursuant to Sections 2 [59A-2-9.8 NMSA 1978] and 3 [61-11-6.2 NMSA 1978] of this 2013 act as sufficient to request prior authorization for prescription drug benefits. No later than twenty-four months after the adoption of national standards for electronic prior authorization, a health insurer shall exchange prior authorization requests with providers who have e-prescribing capability. If a health care plan fails to use or accept the uniform prior authorization form or fails to respond within three business days upon receipt of a uniform prior authorization form, the prior authorization request shall be deemed to have been granted. As used in this section, "health care plan" means a nonprofit corporation authorized by the superintendent to enter into contracts with subscribers and to make health care expense payments but does not include: • a person that only issues a limited-benefit policy intended to supplement major medical coverage, including Medicare supplement, vision, dental, disease-specific, accident-only or hospital indemnity-only insurance policies, or that only issues policies for long-term care or disability income;. Benefits This Health Care Benefit Plan offers Coverage for a wide range of Health Care Services. This Section gives you the details about your benefits, and other requirements, Limitations and Exclusions. Specifically Covered This Health Care Benefit Plan helps pay for health care expenses that are Medically Necessary and Specifically Covered in this Agreement. Specifically Covered means only those Health Care Benefits that are expressly listed and described in the Benefits Section of the Agreement. In addition, you should refer to the Exclusions Section that lists services that are not Covered under your Health Care Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be excluded, except for Clinical Preventive Health Services and except as required by state or federal law. There are no annual or lifetime limits on the dollar value of essential health benefits, as defined under the Affordable Care Act. Presbyterian Health Plan will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost-sharing or other limitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, t...
