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-1.4 - Program restrictions affecting payment for prescribed drugs

Universal Citation: NJ Admin Code 10:167C-1.4

Current through Register Vol. 56, No. 6, March 18, 2024

(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. However, the prescriber's discretion is limited for certain drugs. Reimbursement may be denied if the requirements of the following rules are not met:

1. Covered and non-covered pharmaceutical services as listed in 10:167C-1.12 and 1.13, respectively;

2. Quantity of medication (see 10:167C-1.14 );

3. Pharmaceutical services requiring pharmacist intervention as part of the Senior Gold Prospective Drug Utilization Review (PDUR) program (see 10:167C-1.26 );

4. Dosage and directions (see 10:167C-1.15 );

5. Telephone rendered original prescriptions (see 10:167C-1.16 );

6. Changes or additions to the original prescription (see 10:167C-1.17 );

7. Prescription refill (see 10:167C-1.18 );

8. Prescription Drug Price and Quality Stabilization Act (24:6E-1 et seq.) (see 10:167C-1.19 );
i. Products listed in N.J.A.C. 8:71, distributed to all prescribers and pharmacists; and

ii. Non-proprietary or generic dispensing (see 10:167C-1.10 );

9. Federal regulations ( 42 CFR 447.301, 331 - 333 ) that set the aggregate upper limits on payment for certain multi-source drugs if Federal Financial Participation (FFP) is to be made available. The limit applies to all "maximum allowable costs" (MAC) drugs (see 10:167C-1.5, basis of payment);

10. Drug Efficacy Study Implementation (DESI); "Less than effective drugs" subject to a Notice of Opportunity for Hearing (NOOH) by the Federal Food and Drug Administration (see 10:167C-1.20 and listing of DESI drugs in N.J.A.C. 10:51, Appendix A); and

11. Brand name prescription drugs shall be dispensed pursuant to the requirements for prior authorization set forth in the Fiscal Year 2007 Appropriations Act, P.L. 2006, c. 45, as amended and supplemented by subsequent State appropriations acts.

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