Current through Register Vol. 56, No. 18, September 16, 2024
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed prospective drug utilization review (PDUR) standards recommended by the New Jersey Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of the Department of Human Services (DHS) and the Department of Health and Senior Services (DHSS), the Division of Medical Assistance and Health Services has established a medical exception process (MEP). (See N.J.A.C. 10:51, Pharmaceutical Services)
(b) The MEP shall be administered by a contractor, referred to as the MEP contractor, under a contract with the Department of Human Services.
(c) The MEP shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the NJ DURB, which has been approved by the Commissioners of DHS and DHSS, in accordance with the rules of those Departments.
(d) The MEP is as follows:
1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies that exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Medical Necessity Form (MNF), which includes, but may not be limited to, the beneficiary name, Health Benefits Identification (HBID) number, dispense date, drug quantity and drug description. The prescriber shall be requested to provide the reason for the medical exception, diagnosis, expected duration of therapy and expiration date for medical exception.
ii. The prescriber shall provide information requested on the MNF to the MEP contractor.
2. Following review and approval of a prescriber's written justification, if appropriate, the MEP contractor shall override existing PDUR edits through the issuance of a prior authorization number.
3. The MEP contractor shall notify the pharmacy and prescriber of the results of the review and include, at a minimum, the beneficiary's name, mailing address, HBID number, the reviewer, service description, service date and prior authorization number, if approved, the length of the approval and the appeals process if the pharmacist does not agree with the results of the review.
4. Prescribers may request a fair hearing to appeal decisions rendered by the MEP contractor concerning denied claims (see N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings.)
5. Claims subject to the medical exception process which have not been justified by the prescriber within 30 calendar days shall not be authorized by the MEP contractor and shall not be covered by the Medicaid/NJ FamilyCare programs.
