New Mexico NM

NM (Turquoise Care) has NO statewide preferred drug list today — pharmacy PA criteria live per-MCO and in 8 NMAC Title 8 regulations. Per Bryan (SME), New Mexico will PRODUCE a statewide PDL in 2026. Until it publishes, NM drug_pa_rules stay as-is (no statewide PDL to extract the TX/CA way). Revisit Q3 2026 to find + extract the new PDL.

Last award: 2023-11-07. Next due: Next RFP expected by 2030 for post-option-year cycle. Contracts extended through: 2026-12-31 (base period); optional renewals can extend lineup through ~2031-12-31 max.

New Mexico Medicaid (Turquoise Care, formerly Centennial Care; admin by HCA/Medical Assistance Division, renamed from HSD in 2024) expresses PA in a layered, regulation-anchored shape. (1) FFS criteria/coverage live in the NM Administrative Code Title 8 (8 NMAC) Medicaid program-rule chapters — per-service regulatory PDFs (8.300.x general benefit/UR, 8.301-8.302 billing/claims, 8.308.x managed care, 8.310.2 general benefit, 8.312.2 nursing facility, 8.314.5 DD, 8.321.2 specialized BH, etc.), hosted partly on hca.nm.gov/wp-content and partly on a RealTimeSolutions CDN (prod-rf-lambda.rtssaas.com). (2) FFS utilization review/prior approval is performed by a contracted Medicaid Third-Party Assessor (TPA) — historically Molina TPA then Qualis Health/Comagine then current UR vendor — reached via the Utilization Review provider page. (3) FFS pharmacy PA uses the MAD 635 Drug Authorization Request Form (Rev 03/01/2026) plus the state PDL. (4) For the 4 Turquoise Care MCOs (BCBS NM, Molina, Presbyterian, UnitedHealthcare) PA criteria are per-MCO; NM additionally mandates (OSI, 59A-22B / 13.10.31.10 NMAC) a statewide Uniform Prior Authorization Form and a bi-directional electronic carrier portal. There is NO single state-run PA criteria portal; authority is HCA/MAD for FFS (via 8 NMAC + TPA) and per-MCO for managed care. Provider portal/MMIS = Conduent NM Web Portal. NOTE: the pinned pa_index URL /lookingforinformation/prior-authorization/ now 404s; real entry point is /providers/.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# NM — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 5 docs. See [[state_shape_NM]]. Correction pass: the model FABRICATED a WISeR expansion ("Workforce Innovation in Support of Early Recovery") — WISeR is actually CMS's "Wasteful and Inappropriate Service Reduction" Medicare PA model, limited to AZ/NJ/OH/OK/TX/WA, and is NOT applicable to NM. Corrected below. The insulin CPT codes (92360/92361) in the source summaries are implausible for insulin and treated as unverified. ## 1. How NM requires PA New Mexico's Medicaid program, known as Turquoise Care, mandates prior authorization (PA) through a layered regulatory framework that includes the New Mexico Administrative Code Title 8 (8 NMAC), Third-Party Administrator (TPA) utilization review processes, and specific forms like the MAD 635 pharmacy form. For instance, insulin requires step therapy with documentation of failure with first-line agents (the CPT codes cited in source summaries are unverified). The Drug Authorization Form (MAD-635) is used for prescribing specific drugs, necessitating justification such as the trial of other medications and lab values. ## 2. How NM publishes and reports PA New Mexico's Medicaid program utilizes a partially centralized prior authorization portal, though details on its full extent are not provided in the sources. The state's Medical Assistance Division (MAD) administers Turquoise Care and is responsible for publishing and reporting PA requirements. Specific documents such as the MAD 635 Drug Authorization Form and various regulations under Title 8 of the New Mexico Administrative Code provide guidelines and criteria for prior authorization. The billing manual does not specify particular services or drugs subject to PA. ## 3. NM's CMS-0057-F and PA-reform compliance posture New Mexico has a Gold Card Law (cited in sources as NMSA 1978 §§59A-22B-1 through 59A-22B-8; statute citation unverified) that outlines requirements for prior authorization. There is no explicit mention of CMS-0057-F compliance in the source documents, though the state's structured approach to PA suggests alignment with federal guidelines. The Turquoise Care program includes carve-ins for behavioral health (BH) and long-term services and supports (LTSS). (WISeR not applicable — NM is not one of the six WISeR-model states; the model's invented "Workforce Innovation" expansion was incorrect.) ## 4. How NM runs its own program New Mexico's Medicaid program, Turquoise Care, is administered by the Medical Assistance Division (MAD) under the Health Care Authority (HCA). Per source documents, the state operates through a managed care organization (MCO) model with contracts extending through December 31, 2026, renewable optionally until December 31, 2031. The procurement cycle for MCOs is approximately 2.5 years with optional one-year renewals, not exceeding eight years total. The current fiscal agent is Conduent/Gainwell, following a transition from ACS-Inc. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Layered Regulatory Framework**: PA requirements are embedded in a complex structure including specific forms (e.g., MAD 635) and broader Title 8 regulations. - **Managed Care Model with Carve-ins**: Turquoise Care operates through an MCO model with carve-ins for BH and LTSS. - **Transitions in Fiscal Agents**: ACS-Inc → Conduent/Gainwell. ### Missing/Uncertain: - **Centralized Portal Details**: Specifics about functionality and interface not provided. - **WISeR**: Not applicable — NM is not a WISeR-model state (the model's fabricated expansion was incorrect). - **Effective Dates for Specific Documents**: Some documents (e.g., billing manual, general benefit descriptions under Title 8) lack effective dates. - **Step Therapy Details**: Mentioned for insulin, but no detailed guidelines for other drugs/services. - **Gold Card statute citation**: Unverified.