New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM
Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES
Section 10:167C-1.13 - Non-covered pharmaceutical services
Universal Citation: NJ Admin Code 10:167C-1.13
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The following classes of prescription drugs or conditions are not covered under the Senior Gold program.
1.
Prescriptions which are not for medically accepted indications as defined in Section 1927(k)(6) of the Social
Security Act;
2. Drug products for which adequate and accurate
information is not readily available, such as, but not limited to, product literature, package inserts and
price catalogues;
3. Experimental drugs;
4. Medication furnished by a prescriber or an employee of a
prescriber;
5. Medication prescribed for hospital
inpatients;
6. Non-legend drugs other than over the counter
diabetic testing materials; insulin; and insulin needles and/or syringes;
7. Prescriptions written and/or dispensed with nonspecific
directions;
8. Food supplements, milk modifiers, infant formulas,
therapeutic diets, special liquid or powered diets used in the treatment of obesity;
9. Drug products for which final orders have been published by the Food and
Drug Administration, withdrawing the approval of their new drug application (NDA);
10. Drugs or drug products not approved by the Food and Drug
Administration, when such approval is required by Federal law and/or regulation;
11. Radiopaque contrast materials (for example, Telepaque);
12. Drugs for which Federal Financial Participation (FFP) is not available,
including:
i. Drug Efficacy Study Implementation (DESI) drugs and
identical, similar and related drugs (see
10:167C-1.20);
13. Any bundled drug service, except drug product cost which is a component
of a bundled drug service (see 10:167C-1.21);
14.
Preventive vaccines, biological and therapeutic drugs distributed to hospital clinics and/or community health
centers by the New Jersey Department of Health and Senior Services;
15. If the provider has a delivery service, he or she may waive or discount
delivery charges to the recipient but is prohibited from charging more than his or her usual and customary
charge to the general public for delivery; and
16. Electronic
monitoring devices.
(b) Otherwise reimbursable products shall be excluded from payment, under the following condition(s):
1. Products whose costs are found to be in excess of defined costs outlined
in 10:167C-1.5, Basis of payment;
2. Covered diabetic testing materials, which do not offer significant price
and/or therapeutic advantage. The criteria shall be cost and improvement in accuracy over existing
reimbursable products. Therapeutic advantage (in the case of diabetic testing materials, improvement in
accuracy) shall be determined by evaluation of literature and/or cost effectiveness data submitted in support
of a request for admission of a diabetic testing material for inclusion in the list of reimbursable
products;
3. Drug products available in unit-dose packaging and
dispensed to residents in a boarding home or residential care setting or other community-type setting. Other
community-type setting shall not include certain assisted living settings, including assisted living
residency (ALRs), comprehensive personal care homes (CPCHs) and alternative family care (AFC) homes licensed
by the Department of Health;
4. A prescription refilled too soon
as described in 10:167C-1.18(a) 5;
5. Drug products denied payment based on point-of-sale (POS) and
prospective drug utilization review (PDUR) standards adopted by the Senior Gold program. (see
10:167C-1.26); and
6. Cosmetic drugs including drugs used in the treatment of baldness, age
spots and weight loss unless medically necessary. The Medical Exception Process (MEP) specified at
10:167C-1.27 shall be followed to confirm medial
necessity.
(c) Manufacturers and distributors may request the review of a denial of reimbursement for products under (b) above by providing supportive information to previously submitted, within 30 days of the date of the denial. Agency decisions after review of support material is final.
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.