Current through Register Vol. 56, No. 18, September 16, 2024
(a) For pharmacy
claims that exceed Prospective Drug Utilization Review (PDUR) standards
recommended by the New Jersey DUR Board and approved by the Commissioners of
DHS and DOH, the Division of Medical Assistance and Health Services has
established a Medical Exception Process (MEP).
(b) The medical exception process (MEP) 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 New Jersey DUR Board that has been approved by the
Commissioners of DHS and DOH, in accordance with the rules of those
Departments.
(d) The medical
exception process 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 Prescriber
Notification Letter, which includes, but may not be limited to, the beneficiary
name, Medicaid/NJ FamilyCare eligibility identification number, dispense date,
drug quantity, and 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,
Medicaid/NJ FamilyCare eligibility 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.
