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 Use Review (PDUR) standards recommended by the New Jersey Drug Utilization Review Board (NJ DURB) and approved by the Commissioners of DHS and DOH, the Division of Medical Assistance and Health Services has established a Medical Exception Process (MEP). See N.J.A.C. 10:51-2.23for more information on the PDUR program.
(b) The medical exception process shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services.
(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless there is a recommended exemption by the NJ DURB that has been approved by the Commissioners of DHS and DOH, in accordance with the rules of those Departments.
(d) The medical exception process (MEP) is as follows:
1. The MEP contractor shall contact prescribers of conflicting drug therapies, or drug therapies which exceed established PDUR standards, to request written justification to determine medical necessity for continued drug utilization.
i. The MEP contractor shall send a Prescriber Notification Letter which includes, but may not be limited to, the beneficiary name, HSP identification number, dispense date, drug quantity, drug description. The prescriber shall be requested to provide the reason for medical exception, diagnosis, expected duration of therapy, and expiration date for medical exception.
ii. The prescriber shall provide information requested on the Prescriber Notification 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 their review and include, at a minimum, the beneficiary's name, mailing address, identification 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.
