New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD)
Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES
Section 10:167A-1.16 - Quantity of medication

Universal Citation: NJ Admin Code 10:167A-1.16

Current through Register Vol. 56, No. 6, March 18, 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.

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