New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 51 - PHARMACEUTICAL SERVICES MANUAL
Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY
Section 10:51-2.23 - Prospective drug utilization review (PDUR) program

Universal Citation: NJ Admin Code 10:51-2.23

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

(a) The Division of Medical Assistance and Health Services has established a prospective drug utilization review (PDUR) program to assist pharmacy providers with monitoring drug utilization by Medicaid and NJ FamilyCare beneficiaries. As a component of the Medicaid and NJ FamilyCare point-of-sale (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 recommended by the New Jersey Drug Utilization Review (DUR) Board. Similar responses related to 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 approved by the New Jersey DUR Board shall be based on 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 Dr., San Bruno, CA 94066.

2. PDUR standards adopted by the New Jersey Drug Utilization Review (DUR) Board shall be applied to all Medicaid and NJ FamilyCare pharmacy claims resulting from traditional pharmacy services provided in nursing facilities, regardless of the mode of claim submission.

(b) POS participating pharmacy providers shall be required to meet the conditions described in 10:51-2.23.

(c) In addition to POS responses related to adjudication of Medicaid or NJ FamilyCare 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-drug interactions;

2. Maximum/minimum daily dosage;

3. Therapeutic duplication;

4. Drug-age conflicts;

5. Duration of therapy;

6. Drug-pregnancy precautions;

7. Drug-gender conflicts;

8. Under-usage; and

9. Weight-based.

(d) The PDUR program may apply adopted standards based on a severity index approved by the New Jersey DUR Board to determine appropriate pharmacist intervention and/or claim disposition (for example, payment or denial) of Medicaid or NJ FamilyCare fee-for-service 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 the "offer to consult" as described in 13:39-7.14, patient profile record system.

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.
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