Current through Register Vol. 56, No. 18, September 16, 2024
(a)Public Law 1998, c. 124 establishes different
days supply requirements for pharmacy claims based on the drug use history of a PAAD beneficiary. Days supply
limitations for an "Initial Prescription Claim" for PAAD beneficiaries shall be different from days supply
limitations for a "Refill Prescription Claim." The supply requirements established by Public Law 1998, c. 124
will also apply to the Senior Gold Program.
1. "Initial Prescription Claim"
shall mean a Senior Gold 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 Senior Gold claim with a
service date that exceeds a time period based on the service date of the previously paid Senior Gold
claim.
2. "Refill Prescription Claim" shall mean a Senior Gold
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 Senior Gold claim for the same prescription. A Refill
Prescription Claim may have the same or different prescription number.
3. For Senior Gold claims with service dates on or after the initiation of
the program, 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.
ii. The day supply limitation for a Refill Prescription Claim shall be
limited to a 34-day supply or 100 dosage units, whichever is greater.
4. When Senior Gold is the secondary payer to the Medicare Prescription
Drug Program, any days supply standards required pursuant to the Medicare Prescription Drug, Improvement and
Modernization Act of 2003, Pub. L.
108-173, effective December 8, 2003 and the rules promulgated thereunder at
42 CFR §
423.1 et seq., shall supersede the requirements set forth in
10:167C-1.14.
(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 (b) 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 EMC claim after the balance of the medication is dispensed. The pharmacist may dispense the
quantity available and shall notify the beneficiary accordingly.
