Current through Register Vol. 56, No. 18, September 16, 2024
(a) Days supply limitations for an Initial
Prescription Claim for PAAD beneficiaries shall be different from days supply limitations for a Refill
Prescription Claim.
1. As used in this section, "Initial Prescription
Claim" shall mean a PAAD claim for a drug not previously paid by the State during the 200-day calendar period
immediately preceding the service date of a claim being considered for payment; or a PAAD claim with a
service date that has exceeded two times the day's supply reported by the previously paid PAAD claim for the
same prescription.
2. As used in this section, "Refill
Prescription Claim" shall mean a PAAD claim for a previously paid prescription in which the time period
between claims is less than or equal to two times the days supply reported by the previously paid PAAD claim
for the same prescription. A Refill Prescription Claim may have the same or different prescription
number.
3. For PAAD claims where PAAD is the primary payer, the
following days supply limitations shall apply:
i. The days supply
limitation for an Initial Prescription Claim shall be limited to a 34-day supply; and
ii. The days supply limitation for a Refill Prescription Claim shall be
limited to a 34-day supply or 100 dosage units, whichever is greater.
4. PAAD shall accept the days supply limitations of other primary payers,
including, but not limited to Medicare.
(b) Any
medication continuously prescribed regardless of the frequency of administration, for a period of 14 days or
more shall be considered a maintenance medication.
(c) The
pharmacist shall dispense the full quantity of medication prescribed within the limitations described in (a)
above.
(d) Prescriptions shall not be split or reduced in
quantity, unless the quantity prescribed exceeds Program limits, in which case the quantity shall be reduced
to Program limits described in (a) above.
1. Exception: When the full
quantity prescribed (within Program limits) is not available when a prescription is ready to be dispensed,
the pharmacist shall retain the claim form or submit an Electronic Media Claim after the balance of the
medication is dispensed. The pharmacist may dispense the quantity available and shall notify the beneficiary
accordingly.
2. When the item prescribed is packaged from the
manufacturer in quantities higher than PAAD limits, PAAD will waive the 34-day requirement limit for the
reimbursement and allow the prepackaged quantity.
