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-1.19 - Prescription Drug Price and Quality Stabilization Act requirements
Current through Register Vol. 56, No. 18, September 16, 2024
(a) The Prescription Drug Price and Quality Stabilization Act, 24:6E-1 et seq., shall apply to the program. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." The prescriber shall initial one of the statements in addition to signing the prescription blank.
(b) Federal regulations at 42 CFR 447.331 prescribe the aggregate upper limit, or maximum allowable cost (MAC), for certain legend drugs which are applied to Medicaid covered pharmacy services (see (d) below). For claims with service dates on or after the initiation of the Senior Gold Program, these limits shall apply to all MAC drugs (see N.J.A.C. 10:51, Appendix B, incorporated herein by reference) covered by Senior Gold unless the prescriber indicates in his or her own handwriting on each written prescription or follow-up written prescription to a telephone-rendered prescription (see 10:167C-1.5) the phrase "Brand Medically Necessary" and requests prior authorization, if required, pursuant to the requirements of the Fiscal Year 2007 Appropriations Act, P.L. 2006, c. 45, as amended and supplemented by subsequent State appropriations acts, respecting prior authorization for dispensing drugs under the Program. The Federal regulation at 42 CFR 447.331 requires a written statement and does not permit the use of alternatives such as a check-off box initials or prescriber's signature, next to a preprinted statement "Do Not Substitute," nor does it allow a handwritten statement "Do Not Substitute." For purposes of reimbursement, the physician's override capability under 24:6E-1 does not apply to drugs which have a Federal MAC limit.
(c) For claims with service dates on or after the initiation of the Senior Gold Program, a blanket authorization denying substitutions shall not be permitted. Each prescription order shall state "Brand Medically Necessary" in the prescriber's own handwriting and shall include a prior authorization number, if required, pursuant to the requirements of the Fiscal Year 2007 Appropriations Act, P.L. 2006, c. 45, as amended and supplemented by subsequent State appropriations acts, respecting prior authorization for dispensing drugs under the Program. For non-MAC drugs, each prescription order shall follow the requirements of 24:6E-1 et seq. (see (a) above).
(d) The dispenser must always report the actual labeler code and drug product code of the drug dispensed. The package size code reported may differ from the stock package size used to fill the prescription.