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

Universal Citation: NJ Admin Code 10:167C-1.19

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.

1. When the prescriber does not initial "Substitution Permissible" or the "Do Not Substitute" statement on a prescription for a drug product listed in N.J.A.C. 8:71 (see 10:51-1.4(a)9 i), the pharmacist shall substitute from the list of interchangeable products and bill Senior Gold accordingly.

2. When the prescriber initials "Substitution Permissible," the pharmacist shall dispense and bill for one of the less expensive products listed in N.J.A.C. 8:71 as interchangeable with the brand name prescribed.

3. When the prescriber orders by generic name, the formulary does not apply. The pharmacist shall dispense the least expensive, therapeutically effective product available to him or her at the time of dispensing. The product is not required to be from the list of interchangeable products.

4. Whenever the prescriber does not specify that substitution is not permitted and an interchangeable drug product that is listed in the latest issue of the formulary is available for the prescription written, the Program shall reimburse the pharmacy only for the maximum allowable cost of the interchangeable product, less the program co-payment.

5. For non-MAC drugs (see 10:167C-1.5) , when the prescriber initials "Do Not Substitute" and requests prior authorization, the pharmacist shall indicate the prescriber's preference by indication "Medical Certification" and the 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 on the claim form or the similar field in the EMC claim format and shall dispense and bill Senior Gold for the prescribed product. Reimbursement will be the estimated acquisition cost (EAC), as defined in 10:167C-1.5 (see N.J.A.C. 10:51, Appendix D, incorporated herein by reference, Fiscal Agent Billing Supplement for instructions about the claim form or N.J.A.C. 10:51, Appendix E, incorporated herein by reference, regarding the proper EMC claim format).

6. Claims for MAC drugs and in those situations in which a prescriber authorizes, in accordance with (b) below, the dispensing of a brand drug, the pharmacist shall indicate the prescriber's preference by indicating "Medical Certification" and the 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, on the claim form, or similar field in the EMC claim format and shall dispense and bill Senior Gold for the prescribed product. Reimbursement will be the estimated acquisition cost (EAC) (see 10:167C-1.5) plus applicable dispensing fee or the usual and customary charge, whichever is less for that product (see N.J.A.C. 10:51, Appendix D, incorporated herein by reference, Fiscal Agent Billing Supplement for instructions about the claim form or N.J.A.C. 10:51, Appendix E, incorporated herein by reference, regarding the proper EMC claim format).

(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.

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.