New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL
Subchapter 5 - APPLICATION PROCESS
Section 10:167B-5.4 - Exceptions from normal standards

Universal Citation: NJ Admin Code 10:167B-5.4

Current through Register Vol. 56, No. 18, September 16, 2024

(a) There may be exceptional cases where the processing of an eligibility application cannot be completed within a normal 30-day period. Where substantially reliable evidence either of eligibility or ineligibility is still lacking, the application shall be continued in pending status. In each such case, however, the Department shall be prepared to demonstrate that the delay resulted from one of the following:

1. Circumstances wholly within the applicant's control;

2. A determination to afford to an applicant whose proof of eligibility has been inconclusive, further opportunity to develop additional evidence of eligibility before final action is taken on the application;

3. An administrative or other emergency that could not reasonably have been avoided; or

4. Circumstances wholly outside of the control of both the applicant and the Program.

(b) A Senior Gold applicant who meets all the Senior Gold eligibility criteria can reasonably expect to receive his or her Senior Gold eligibility card within 30 days from the date that a complete and valid eligibility application is received by the Program.

(c) In the event that mailing of the eligibility card is delayed, the Program will reimburse the Senior Gold beneficiary directly for the cost (minus a $ 15.00 co-payment plus 50 percent of the remaining prescription cost per prescription) of all prescription drugs purchased by the person on or after the 30th day after his or her valid and properly completed application was received by the Program, subject to the following conditions:

1. The eligibility renewal application must have been fully and properly completed;

2. The beneficiary must submit a prescription claim form and proof of purchase for each eligible prescription to the Program. The claim form must be completed by a participating New Jersey pharmacy, or by a licensed mail order pharmacy service program where the prescription is delivered to a New Jersey address; and

3. No direct reimbursement will be made for any drugs purchased after the date when the beneficiary receives his or her eligibility identification card.

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