Current through Register Vol. 56, No. 24, December 18, 2024
(a) The provider shall obtain prior
authorization, when required by this chapter, by phone or in writing, from the
professional staff of the Division's prior authorization agent for pharmacy
services. The pharmacy prior authorization agent is available at a toll-free
telephone number 24 hours a day, seven days a week. When a form is required by
this chapter, the appropriate form that must be used to request prior
authorization is indicated in the Fiscal Agent Billing Supplement. Information
on the form is transmitted, on-line, from the pharmacy prior authorization
agent to the fiscal agent who, in turn, confirms the status of the
authorization request by mail and provides the specific prior authorization
number.
1. In an administrative emergency
(see N.J.A.C. 10:49-6.1(b)3 )
when the pharmacy prior authorization agent is unavailable, the provider may
dispense a 72 hour supply of the prescribed drug.
i. If the drug is to be continued beyond 72
hours, and the pharmacy prior authorization agent is unavailable, the provider
may dispense a total of a five day's supply. If the drug is to be continued
either beyond the 72 hours or five days period, the provider shall hold the
claim and obtain prior authorization for the balance of the prescription when
the pharmacy prior authorization agent is available during normal business
hours.
(b)
The following drugs and specific therapeutic classes require prior
authorization:
1. Enteral nutritional products
and special infant formulas may only be authorized when medically necessary and
when not available from the Women, Infants and Children (WIC) Nutritional
program;
i. Medically necessary enteral
nutritional products for treatment of beneficiaries, which may be administered
orally, via naso-gastric tube, gastrostomy tube or needle catheter jejunostomy
must be prior authorized. Special liquid or powdered diets for treatment of
obesity or regular infant formulas are not considered enteral nutritional
products;
ii. Electrolyte
replacement supplements are not considered enteral nutritional supplements and
do not require prior authorization.
2. Methadone (not eligible for reimbursement
when used for drug detoxification or for addiction maintenance);
3. Drugs available only for treatment through
an Investigational New Drug (IND) application;
4. Anorexiants and antiobesics when used for
the treatment of conditions approved by the New Jersey State Board of Medical
Examiners at
N.J.A.C. 13:35-6.7;
5. Lipase inhibitors, used in the treatment
of obesity, as follows:
i. The provider shall
telephone the pharmacy prior authorization agent, using the toll-free telephone
number supplied by the Division. Pharmacy prior authorization is available 24
hours a day, seven days a week. The pharmacy prior authorization agent reviews
the information provided and automatically prior-authorizes a 30-day supply.
Subsequent authorizations are based on criteria established by the New Jersey
Drug Utilization Review Board, as specified in ii below.
ii. The lipase inhibitors will be provided
for an initial 30-day period. A prior authorization will be issued without
clinical criteria for an initial prescription for a maximum 30-day supply.
During this initial 30-day period, the pharmacy prior authorization agent will
contact the physician to request justification for continuing the use of the
lipase inhibitor. If justification is received by the pharmacy prior
authorization agent, the lipase inhibitor will be prior authorized for an
additional 30-day supply. After these two 30-day periods, any subsequent
provision of lipase inhibitors shall not be dispensed without prior
authorization. Such subsequent prior authorizations for lipase inhibitors shall
be limited to 90-day supply; and
6. Any prescription claim for the same
beneficiary, provided within the same calendar month, that exceeds the monthly
prescription volume threshold of 12 prescriptions per month. This applies
whether the prescriptions were dispensed by one or more pharmacies. The need
for prior authorization shall be communicated to providers via the point of
sale claims processing system. Prior authorization shall be requested as
required by (a) above, except that prior authorization shall not be required in
the following circumstances:
i. Pharmaceutical
services provided to Medicaid beneficiaries residing in a nursing facility,
assisted living residence, comprehensive personal care home, or residential
health care facility;
ii. Certain
drugs and specific therapeutic drug classes including clozapine,
antihemophiliac drugs, immunosuppressants, and HIV/AIDS drugs (limited to
protease inhibitor, antiretroviral drugs, nucleoside analogs and reverse
transcriptase inhibitors);
iii.
Certain legend drugs, including oral contraceptives, ophthalmic preparations,
otic preparations, nitroglycerin patches, vaginal preparations, and
hemorrhoidal preparations;
iv.
Drugs otherwise requiring prior authorization in accordance with this
subsection;
v. Drugs otherwise
requiring prior authorization by the Work First New Jersey/General Assistance
program; and
vi. Drugs dispensed to
beneficiaries in the pharmacy lock-in program.