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-1.26 - Prospective drug utilization review (PDUR) program

Universal Citation: NJ Admin Code 10:167C-1.26

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

(a) The Drug Utilization Review (DUR) Board was established by law on June 30, 1998 ( P.L. 1998, c. 41). A fully operational edit system began on December 1, 1999. The Division of Medical Assistance and Health Services of the Department of Human Services and the Department of Health have established a prospective drug utilization review (PDUR) program to assist pharmacy providers in monitoring drug utilization by Senior Gold beneficiaries. As a component of the Senior Gold POS claims adjudication system, the State's fiscal agent will review drug utilization based on claims submitted on-line and provide pharmacists with responses in real-time regarding utilization within PDUR standards as recommended by the DUR Board and approved by the Department. Similar responses related to electronic media claims (EMC) or paper claims processed by the New Jersey Medicaid Management Information System (NJMMIS) shall be received by pharmacies on the Remittance Advice statement.

1. PDUR standards developed by the DUR Board shall be based on official compendia and accepted medical literature and shall include, but not be limited to, those standards established by First Data Bank (FDB) as part of the FDB DUR information system. The FDB standards are incorporated herein by reference and may be obtained from First Data Bank, The Hearst Corp., 1111 Bayhill Drive, San Bruno, CA 94966.

2. PDUR standards shall be applied to all Senior Gold pharmacy claims, regardless of the mode of claim submission.

(b) POS participating pharmacy providers shall be required to meet the conditions described in 10:167C-1.25.

(c) In addition to POS responses related to adjudication of Senior Gold pharmacy claims returned to the pharmacy, pharmacists shall be notified regarding drug utilization inconsistent with adopted PDUR standards which may include, but not be limited to:

1. Drug interactions;

2. Maximum/minimum daily dosage alerts;

3. Therapeutic duplication;

4. Drug age conflicts;

5. Duration of therapy;

6. Drug-disease precautions; and

7. Drug-pregnancy precautions.

(d) The PDUR program may apply adopted standards based on a severity index approved by the Department or DUR Board to determine appropriate pharmacist intervention and/or claim disposition (for example, payment or denial) of Senior Gold pharmacy claims.

(e) Based on the severity of a potential PDUR conflict or interaction, pharmacists shall be required to consult with the beneficiary and/or prescriber to resolve matters indicated by PDUR messages returned by the POS system.

(f) The pharmacist intervention requirements related to the PDUR program are in addition to beneficiary interactions related to New Jersey State Board of Pharmacy requirements regarding the "offer to consult," as described in 13:39-7.14, Patient profile record system.

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