New Jersey Administrative Code
Title 11 - INSURANCE
Chapter 4 - ACTUARIAL SERVICES
Subchapter 62 - PHARMACY BENEFITS MANAGERS
Section 11:4-62.4 - Appeals

1. The right to appeal shall be limited to 14 calendar days following the initial claim;

2. The appeal shall be investigated and resolved by the pharmacy benefits manager through an internal process within 14 calendar days of receipt of the appeal by the pharmacy benefits manager; and

3. A telephone number at which a pharmacy may contact the pharmacy benefits manager and speak with an individual who is involved in the appeals process.

1. If the appeal is denied, the pharmacy benefits manager shall provide the reason for the denial and identify the national drug code of a drug product that is available for purchase by contracted pharmacies in this State from wholesalers registered pursuant to N.J.S.A. 24:6B-1 et seq., at a price which is equal to or less than the maximum allowable cost for the appealed drug as determined by the pharmacy benefits manager; and

2. If the appeal is approved, the pharmacy benefits manager shall make the price correction, permit the reporting pharmacy to reverse and rebill the appealed claim, and make the price correction effective for all similarly situated pharmacies from the date of the approved appeal.