reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.2 - Income standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Any single permanent resident of New
				Jersey who is 65 years of age or over or who is under 65 and over 18 years of
				age and is receiving Social Security Title II disability benefits must have a
				total annual income between $ 28,769 and $ 38,769 in 2021 to be eligible for
				Senior Gold benefits. These income limits will increase January 1 of each year
				in accordance with the Social Security cost of living adjustment. This amount
				shall not be more than $ 10,000 above the applicable PAAD income eligibility
				limits for single persons. Recipients of other State-funded prescription
				discount benefits are not eligible for the Senior Gold Prescription Discount
				Program.
(b) Any married permanent
				resident of New Jersey who is 65 years of age or who is under 65 and over 18
				years of age and is receiving Social Security Title II disability benefits must
				have a total annual income between $ 35,270 and $ 45,270 in 2021 to be eligible
				for Senior Gold benefits. The income limits will increase January 1 of each
				year in accordance with the Social Security cost of living adjustment. This
				amount shall not be more than $ 10,000 above the applicable PAAD income
				eligibility limits for married couples. Recipients of other State-funded
				prescription discount benefits are not eligible for the Senior Gold
				Prescription Discount Program.
1. An applicant
				and spouse shall be considered separated and eligibility determined under the
				single income standard when each maintains a separate residence and the
				applicant does not have access to the spouse's income.
i. Any support payment received by the
				applicant for the sole benefit of the applicant shall be considered as income
				for Senior Gold eligibility purposes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.3 - Citizenship

Current through Register Vol. 56, No. 14, July 15, 2024
A person shall not be required to be a citizen of the United
				  States in order to be eligible for Senior Gold.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.4 - Residence

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Resident"
				means a resident as defined in section 3 of P.L. 1975, c.194 (30:4D-22 ) for purposes of
				eligibility for PAAD. Resident means one legally domiciled within the State for
				a period of 30 days immediately preceding the date of application for inclusion
				in the Program. Mere seasonal or temporary residence within the State, for
				whatever duration, does not constitute domicile. Absence from this State for a
				period of 12 months is prima facie evidence of abandonment of domicile. The
				burden of establishing legal domicile within the State is upon the applicant.
1. The term resident shall be interpreted to
				mean a person having his or her customary place of abode in New Jersey. The
				fact that an individual was or may have been motivated to move to New Jersey
				because of the availability of medical facilities does not, of itself, justify
				a finding that he or she has established a residency in this State; however,
				such inquiry need not be made if an individual has been physically present in
				New Jersey for a period exceeding three months.
2. The applicant must be able to substantiate
				residence upon request by the Department and is required to submit photocopies
				of two documents showing evidence of current residence at the time of initial
				application.
3. Senior Gold
				beneficiaries are entitled to prescription benefits only when the beneficiary
				is physically present in the State of New Jersey at the time the prescription
				is dispensed.
4. The following are
				examples of sources of evidence of residence:
i. Motor vehicle records (for example, valid
				driver's license);
ii. Landlord's
				records and rent receipts;
iii.
				Public utility records and receipts (for example, electric bill);
iv. Personal property assessment
				records;
v. Records of business or
				professional people, such as doctors, department stores, etc.;
vi. Post Office records;
vii. Records of social agencies, public or
				private; and
viii. Employment
				records.
5.
				Determination as to continued New Jersey residence of a person absent from this
				State shall be based upon contact with the applicant by a representative of the
				Department.
6. In reaching a
				decision as to continuing New Jersey residence of an absentee, the issue is
				whether the individual intends to return to New Jersey or remain indefinitely
				in the other jurisdiction. If a beneficiary leaves New Jersey with the intent
				to establish a place of abode elsewhere, he or she becomes ineligible under the
				Program and must notify the Program of the address and return the Senior
				Discount eligibility card.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.5 - Recipient of other assistance and pharmaceutical coverage

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Senior Gold
				Prescription Discount Act provides that an eligible person whose prescription
				drug costs are covered in part by any other program or plan of assistance or
				insurance may be required to receive reduced assistance under the Program. If
				an eligible person's prescription drug costs are covered in whole or in part by
				any other program or plan of assistance of insurance, the other program or plan
				shall be the primary payer, and the Program shall be the payer of last
				resort.
(b) Individuals with
				coverage described in (a) above must submit their prescriptions for payment to
				the other program or plan of assistance or insurance for payment before
				submitting the prescription for payment by the Senior Gold Prescription
				Discount Program.
(c) The Senior
				Gold Prescription Discount Act establishes the co-payment for each prescription
				to be paid by an eligible individual.
(d) At the time of each purchase of a
				prescription drug, the eligible person shall pay a co-payment that shall not be
				waived, discounted or rebated in whole or in part.
(e) When an eligible individual has
				prescription costs paid in part by any other program or plan of assistance or
				insurance, the amount paid by the Program, when combined with the payment made
				by the other program or plan of assistance or insurance, shall not exceed the
				amount that the Program would pay if no other coverage was available.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.6 - Senior Gold eligibility application and renewal application forms

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Senior Gold
				Eligibility application (Form SG-1) is the only acceptable form to be utilized
				in determining the applicant's initial eligibility for Senior Gold. These
				applications and brochures are available at the local Social Security Office,
				the County Office on Aging, the Office of Disability Services, pharmacies and
				the Internet.
(b) Senior Gold
				Eligibility renewal application forms (Form SG-2) will be automatically mailed
				to the beneficiary approximately four months prior to the eligibility
				expiration date. This is the only acceptable form to be utilized in renewing
				Senior Gold Program eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.7 - Social Security account number

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Senior Gold
				applicants are not required to submit their Social Security Account Number
				(SSAN); however, failure to provide it will delay the processing of their
				application. Each applicant for Senior Gold benefits must include his or her
				SSAN on the application/reapplication form. The SSAN is a unique and verifiable
				number which is utilized to differentiate between persons with the same name.
				Married persons are asked to also indicate the SSAN of their spouse.
(b) In the event that the applicant does not
				have a SSAN, a unique identifying number will be assigned by the Program. This
				number will be used throughout the beneficiary's Senior Gold
				eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.8 - Certification

Current through Register Vol. 56, No. 14, July 15, 2024
The applicant for Senior Gold benefits must certify that all
				  the answers to the questions and items on the application/renewal application
				  form are true and accurate to the best of his or her knowledge. This
				  certification must be dated, signed or marked by the applicant and spouse (if
				  married), and the preparer of the form (if other than the applicant), before
				  the application/renewal application can be processed.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.9 - Authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) By signing or
				marking the certification and authorization statement on a Senior Gold
				eligibility application or a renewal application form, an applicant or a
				reapplicant authorizes:
1. The Department to
				serve as the authorized representative of the applicant or
				reapplicant;
2. The Department to
				verify any information on the form by contacting the Social Security
				Administration, the Internal Revenue Service, the New Jersey Division of
				Taxation, employers and others as the need arises;
3. Visitation and review by representatives
				of the Department;
4. Assignment of
				benefits to the State of New Jersey if he or she or his or her spouse has any
				other plan of assistance or insurance that covers, at least in part, the cost
				of prescription drugs; and
5.
				Prescribing practitioners to release information concerning prescriptions which
				have been paid by the Senior Gold Program to the Department or any law
				enforcement authority of this State charged with the investigation or
				prosecution of violations of the civil and criminal provisions of the "Senior
				Gold Prescription Discount Act" or the criminal laws of this State.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.10 - Eligibility period

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Senior Gold
				eligibility card is effective for the dates indicated on the card. The Senior
				Gold beneficiary shall renew his or her eligibility in accordance with the
				provisions of
				10:167B-6.6.
(b) Renewal applications must be completed
				and returned to the Senior Gold Program by the beneficiary at least 45 days
				prior to the expiration date to ensure continuous coverage.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.12 - Appeal process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When the
				Program determines that an applicant is ineligible for benefits, the applicant
				has the right to appeal the decision by submitting a written request for a fair
				hearing to the Senior Gold Prescription Discount Program, PO Box 724, Trenton,
				New Jersey 08625-0724, within 30 calendar days from the date of mailing of the
				notice of ineligibility. The document must clearly state the basis for such a
				request.
(b) The Program will
				forward the hearing request, if determined to be a contested case, to the
				Office of Administrative Law which will schedule the hearing and notify all
				parties of the date, time and location of the hearing.
(c) The petitioner will have the burden of
				demonstrating that the Program's determination deviates from the requirements
				and standards of the regulations and statute.
(d) When the Senior Gold beneficiary requests
				a fair hearing, he or she shall clearly indicate the existence of a disputed
				question or fact or law arising from the requirements and standards of the
				rules and statutes of the Senior Gold Program. If the beneficiary fails to
				establish a contested case, the Senior Gold Program shall deny the hearing
				request. Hearings are not intended to be informational or to provide a forum
				for the expression of public sentiment on Senior Gold actions or
				policies.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167B-7.1 - Recoveries for benefits correctly paid

Current through Register Vol. 56, No. 14, July 15, 2024
No encumbrance or recovery of any kind shall be imposed or
				  sought from the estate of a qualified applicant or an eligible person after his
				  or her death because of assistance paid, or to be paid, on his or her behalf
				  under the Senior Gold Program, except for assistance incorrectly or illegally
				  paid, or for third party liability recovery sought under the New Jersey Medical
				  Assistance and Health Services Act, P.L. 1968, c.413, codified as
				  30:4D-1 et seq.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167B-7.2 - Recoveries for benefits incorrectly paid

Current through Register Vol. 56, No. 14, July 15, 2024
(a) As provided in
				30:4D-1 et seq., the Department
				may take all necessary action to recover the cost of benefits incorrectly paid
				on behalf of a beneficiary in accordance with
				30:4D-45.1.
1. The term "incorrect payment" includes, but
				is not limited to:
i. Payment made on behalf
				of a beneficiary whose drug costs are wholly covered by another
				source;
ii. Payment made on behalf
				of a beneficiary who is no longer eligible or has been incorrectly determined
				to be eligible to receive benefits; and
iii. Payment made as a result of fraud
				perpetrated by a beneficiary, his or her authorized agent and/or
				provider.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167B-7.3 - Liens

Current through Register Vol. 56, No. 14, July 15, 2024
Provisions for the application of liens shall be consistent
				  with and conform to any provisions for liens as provided in
				  30:4D-1 et seq.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 7 - RECOVERIES AND LIENS › Section 10:167B-7.4 - Penalties

Current through Register Vol. 56, No. 14, July 15, 2024
Any person violating any provision of the Senior Gold
				  Prescription Discount Act shall be subject to the applicable civil and criminal
				  penalties contained in the New Jersey Medical Assistance and Health Services
				  Act, 30:4D-1 et seq. In addition, any
				  eligible person who violates any provision of the Senior Gold Prescription
				  Discount Act shall be subject to a suspension of their eligibility for one year
				  for a first offense and permanent revocation of their eligibility for a second
				  offense.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) It is intended
				that the Senior Gold Prescription Discount Program shall extend assistance to
				certain persons whose level of income disqualifies them for benefits and
				medical assistance under the New Jersey Medical Assistance and Health Services
				Act and for prescription benefits under the Pharmaceutical Assistance to the
				Aged and Disabled (PAAD) Act, but who have significant needs for more
				affordable prescription drugs.
(b)
				This chapter has been developed as a statement of policy and procedures and is
				applicable only to eligibility for the Senior Gold Prescription Discount
				Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.2 - Participation of eligible providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A pharmacy,
				with a retail or institutional permit, may participate in the Senior Gold
				Program as a provider of pharmaceutical services.
(b) To be approved as a provider of
				pharmaceutical services, the pharmacy shall:
1. Operate under a valid retail and/or
				institutional permit issued by the Board of Pharmacy of the State of New
				Jersey. A pharmacy operating under an out-of-State retail or institutional
				pharmacy permit may not participate as an approved provider in the Senior Gold
				Program;
2. File an application and
				sign an agreement with the Department of Human Services (DHS), Division of
				Medical Assistance and Health Services (DMAHS).
i. Upon sale or other change of ownership of
				an approved pharmacy, the agreement is automatically terminated. To execute a
				new agreement to participate in the Program, the new owner(s) shall apply to
				the Division of Medical Assistance and Health Services, Department of Human
				Services, by contacting the Medicaid Provider Enrollment Unit (see N.J.A.C.
				10:49, Administration) or the fiscal agent Provider Enrollment Unit.
ii. To enroll as a Senior Gold provider of
				pharmaceutical services, a pharmacy shall contact the Fiscal Agent Provider
				Enrollment Unit (see N.J.A.C. 10:51, Appendix D, Fiscal Agent Billing
				Supplement).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.3 - Conditions for participation as a provider of pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All
				participating pharmacies shall provide complete prescription services,
				including injectables and injectable anti-neoplastic agents, compounding, and
				prescription refill services, when allowable. Prescriptions must be dispensed
				in compliance with all current existing Federal and State laws.
(b) All drugs must be prescribed.
1. "Prescribed drugs" mean simple or
				compounded substances or mixtures of substances prescribed for the cure,
				mitigation, or prevention of disease, or for health maintenance that are:
i. Prescribed by a practitioner licensed or
				authorized by the State of New Jersey, or the state in which he or she
				practices, to prescribe drugs and medicine within the scope of his or her
				license and practice;
ii. Dispensed
				by licensed pharmacists in accordance with regulations promulgated by the New
				Jersey State Board of Pharmacy, N.J.A.C. 13:39; and additional prescription
				pricing information in accordance with P.L. 1994, c.67, as revised by P.L.
				1995, c.5 (see
				10:167C-1.13(b) 
				); and
iii. Dispensed by a licensed
				pharmacist on the basis of a written prescription that is recorded and
				maintained in the pharmacist's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.4 - Program restrictions affecting payment for prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The choice of
				prescribed drugs shall be at the discretion of the prescriber within the limits
				of applicable laws. However, the prescriber's discretion is limited for certain
				drugs. Reimbursement may be denied if the requirements of the following rules
				are not met:
1. Covered and non-covered
				pharmaceutical services as listed in
				10:167C-1.12 and 1.13,
				respectively;
2. Quantity of
				medication (see
				10:167C-1.14 );
3. Pharmaceutical services requiring
				pharmacist intervention as part of the Senior Gold Prospective Drug Utilization
				Review (PDUR) program (see
				10:167C-1.26 );
4. Dosage and directions (see
				10:167C-1.15 );
5. Telephone rendered original prescriptions
				(see 10:167C-1.16 );
6. Changes or additions to the original
				prescription (see
				10:167C-1.17 );
7. Prescription refill (see
				10:167C-1.18 );
8. Prescription Drug Price and Quality
				Stabilization Act (24:6E-1 et seq.) (see
				10:167C-1.19 );
i. Products listed in N.J.A.C. 8:71,
				distributed to all prescribers and pharmacists; and
ii. Non-proprietary or generic dispensing
				(see 10:167C-1.10 );
9. Federal regulations ( 42 CFR
				447.301, 331 - 333 ) that set the aggregate upper limits on payment for certain
				multi-source drugs if Federal Financial Participation (FFP) is to be made
				available. The limit applies to all "maximum allowable costs" (MAC) drugs (see
				10:167C-1.5, basis of
				payment);
10. Drug Efficacy Study
				Implementation (DESI); "Less than effective drugs" subject to a Notice of
				Opportunity for Hearing (NOOH) by the Federal Food and Drug Administration (see
				10:167C-1.20 and listing of DESI
				drugs in N.J.A.C. 10:51, Appendix A); and
11. Brand name prescription drugs shall be
				dispensed pursuant to the requirements for prior authorization set forth in the
				Fiscal Year 2007 Appropriations Act,
				P.L.
				2006, c. 45, as amended
				and supplemented by subsequent State appropriations acts.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.5 - Basis of payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section
				provides a summary of the elements involved in the calculation of the payment
				of legend or certain non-legend drugs. The elements include the following:
1. Program restrictions affecting
				reimbursement for the dispensing of drugs as listed in
				10:167C-1.4;
2. Price information as supplied from a
				reference drug file subcontracted for this purpose by the fiscal agent and
				accepted by the Division of Medical Assistance (Medicaid) as the primary source
				of pricing information for the New Jersey Medicaid Management Information
				System (NJMMIS). If reimbursement for a drug is not covered under the Medicare
				Prescription Drug Program, the drug price shall not exceed the lower of the
				reimbursement standard set forth in the Fiscal Year 2007 Appropriations Act,
				P.L.
				2006, c. 45, as amended
				and supplemented by subsequent State appropriations acts, the provider's usual
				and customary charge; or the drug's maximum allowable cost, if applicable (see
				(b) below);
i. The NJMMIS reference drug file
				is updated periodically by the fiscal agent based upon data supplied by First
				Data Bank (FDB). The update process provides the fiscal agent with current data
				to include changes in product description. Providers are made aware of
				therapeutic indications for various classes of drugs by product literature
				distributed by drug manufacturers and by various trade publications. Based on
				market information, providers can determine whether a product's therapeutic
				classification meets the criteria specified in
				10:167C-1.12, Covered
				pharmaceutical services;
3. Federal regulations ( 42 CFR 447.301, 331
				- 333 ) that set the aggregate upper limits on payment for certain covered
				drugs in the Program. The New Jersey Medicaid program refers to these upper
				limits as the "maximum allowable cost" (see (b) below); and
4. Provider's usual and customary charge for
				legend drugs (see (c) below), insulin, insulin needles and syringes, or
				diabetic testing materials.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.6 - Pharmacy discounts

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Those pharmacy
				providers who have been in business for less than one calendar year shall have
				their prescription volume projected for the entire year, to determine the
				appropriate dispensing fee.
(b) The
				Division of Medical Assistance (Medicaid) shall determine a provider's total
				prescription volume, which includes all prescriptions filled (both new and
				refills), including nursing facility prescriptions, for private patients,
				Medicaid, Senior Gold and other third party recipients for the previous
				calendar year.
(c) The pharmacy
				shall submit in writing an annual report on form FD-70 as required by N.J.A.C.
				10:51, Appendix C to certify prescription volume.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.7 - Prescription drug dispensing fee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The dispensing
				fee for each prescription, dispensed by providers having retail permits to
				recipients other than those in nursing facilities, is $ 3.73. Additional
				dispensing fees (add-ons) per prescription shall be given to pharmacy providers
				who provide the following:
1. Twenty-four
				hour emergency service: $ 0.11. The provider shall have a 24-hour per day, 365
				days per year prescription service available and shall have provided Senior
				Gold beneficiaries opportunities to utilize this service.
2. Patient consultations: $ 0.08. In addition
				to routinely monitoring recipient profiles for drug interactions,
				contra-indications, allergies, etc., the provider shall, where appropriate,
				discuss the course of drug therapy with the recipient. This discussion must
				include emphasis on compliance with the prescriber's orders; proper drug
				utilization; cautions about possible side effects; foods to avoid; proper drug
				storage conditions; and any other information that will prove beneficial to the
				recipient while on drug therapy.
3.
				Impact area location: $ 0.15. The provider shall have a combined Medicaid and
				Senior Gold prescription volume equal to or greater than 50 percent of the
				provider's total prescription volume.
i. The
				nursing facility prescription volume shall be included for the determination of
				total prescription volume in determining entitlement to the impact
				allowance.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.8 - Senior Gold Program co-payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Beneficiaries
				in the Program are responsible for a part of the cost of drugs and devices
				covered by the Program. At the point of sale, a Senior Gold beneficiary shall
				render to a pharmacy provider a fixed co-payment of $ 15.00 plus 50 percent of
				the remaining cost of the drug.
(b)
				A co-payment shall be rendered to a pharmacy provider for each original or
				refill prescription dispensed. The provider's usual and customary charge billed
				to the Program shall be inclusive of the co-payment amount which will be
				deducted by the New Jersey Medicaid Management Information System (NJMMIS).
1. Under no circumstances is the required
				rendered co-payment amount to be waived for reasons of promotion, advertisement
				and/or competitive considerations. Failure to comply with Program co-payment
				requirements may result in a suspension of a provider's approval to participate
				in the Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.9 - Compounded prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Compounded
				prescriptions may be reimbursed by the Program. Compounded prescriptions are
				extemporaneously prepared mixtures of an active ingredient or ingredients
				and/or a pharmaceutical excipient or excipients and are dispensed by approved
				providers.
1. Acceptable pharmaceutical
				excipients which do not contribute therapeutically to a compound, include, but
				are not limited to hydrophilic ointment, petrolatum, aquifer, eucerin cream,
				phenol, menthol, resorcinol, caffeine, talc, simple syrup, aromatic elixir,
				distilled water, and glycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.10 - Non-proprietary or generic dispensing

Current through Register Vol. 56, No. 14, July 15, 2024
When medication is prescribed by its non-proprietary or
				  generic name, the pharmacist shall dispense the least expensive,
				  therapeutically effective equivalent product available, preferably one listed
				  in N.J.A.C. 8:71. The labeler code and drug product code of the actual product
				  dispensed must be reported on the claim form. The package size code reported
				  may differ from the stock package size used to fill the prescription.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.11 - Provider's usual and customary charge or advertised charge

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The provider's
				usual and customary charge or advertised charge is an element considered in the
				calculation of the basis of payment for legend drugs (see
				10:167C-1.5, Basis of
				payment).
(b) The usual and
				customary charge to the Program is defined as the amount a provider charges the
				general public for a prescription for the same drug product (same NDC number)
				in the same quantity as the prescription being dispensed to a Senior Gold
				beneficiary. "Usual and customary charge" means the actual charge made to the
				majority (51 percent) of the total patient population served by the individual
				pharmacy.
1. The provider shall not charge
				the program more than would be charged to a cash customer when the general
				public, including private third party plans, accounts for more than 50 percent
				of a provider's total prescription volume.
i.
				In the event Medicaid and/or Senior Gold represent more than 50 percent of a
				provider's total prescription volume, then, for reimbursement purposes, the
				provider's usual and customary charge may be considered the amount the Program
				would reimburse for the same services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.12 - Covered pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered
				pharmaceutical services shall be provided within the scope of the Medicaid or
				Senior Gold programs, and billed to the fiscal agent on the claim form or other
				approved billing method (see N.J.A.C. 10:51, Appendix D, incorporated herein by
				reference, Fiscal Agent Billing Supplement).
(b) Covered pharmaceutical services include:
1. Prescribed legend drugs (for their
				medically accepted indication) as defined in Section 1927(k)(6) of the Social
				Security Act. "Legend drugs" mean those drugs whose labels include the legend
				statement "Caution: Federal Law Prohibits Dispensing without a prescription.";
				and
2. Non-legend drugs, as follow:
i. Diabetic testing materials;
ii. Insulin needles;
iii. Insulin; and
iv. Syringes and needles for injectable
				medicines for the treatment of multiple sclerosis.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.13 - Non-covered pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following
				classes of prescription drugs or conditions are not covered under the Senior
				Gold program.
1. Prescriptions which are not
				for medically accepted indications as defined in Section 1927(k)(6) of the
				Social Security Act;
2. Drug
				products for which adequate and accurate information is not readily available,
				such as, but not limited to, product literature, package inserts and price
				catalogues;
3. Experimental
				drugs;
4. Medication furnished by a
				prescriber or an employee of a prescriber;
5. Medication prescribed for hospital
				inpatients;
6. Non-legend drugs
				other than over the counter diabetic testing materials; insulin; and insulin
				needles and/or syringes;
7.
				Prescriptions written and/or dispensed with nonspecific directions;
8. Food supplements, milk modifiers, infant
				formulas, therapeutic diets, special liquid or powered diets used in the
				treatment of obesity;
9. Drug
				products for which final orders have been published by the Food and Drug
				Administration, withdrawing the approval of their new drug application
				(NDA);
10. Drugs or drug products
				not approved by the Food and Drug Administration, when such approval is
				required by Federal law and/or regulation;
11. Radiopaque contrast materials (for
				example, Telepaque);
12. Drugs for
				which Federal Financial Participation (FFP) is not available, including:
i. Drug Efficacy Study Implementation (DESI)
				drugs and identical, similar and related drugs (see
				10:167C-1.20 );
13. Any bundled drug service,
				except drug product cost which is a component of a bundled drug service (see
				10:167C-1.21 );
14. Preventive vaccines, biological and
				therapeutic drugs distributed to hospital clinics and/or community health
				centers by the New Jersey Department of Health and Senior Services;
15. If the provider has a delivery service,
				he or she may waive or discount delivery charges to the recipient but is
				prohibited from charging more than his or her usual and customary charge to the
				general public for delivery; and
16. Electronic monitoring devices.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.14 - Quantity of medication

Current through Register Vol. 56, No. 14, July 15, 2024
(a)Public Law 1998,
				c. 124 establishes different days supply requirements for pharmacy claims based
				on the drug use history of a PAAD beneficiary. Days supply limitations for an
				"Initial Prescription Claim" for PAAD beneficiaries shall be different from
				days supply limitations for a "Refill Prescription Claim." The supply
				requirements established by Public Law 1998, c. 124 will also apply to the
				Senior Gold Program.
1. "Initial Prescription
				Claim" shall mean a Senior Gold claim for a drug not previously paid by the
				State during the 200-day calendar period immediately preceding the service date
				of a claim being considered for payment; or a Senior Gold claim with a service
				date that exceeds a time period based on the service date of the previously
				paid Senior Gold claim.
2. "Refill
				Prescription Claim" shall mean a Senior Gold claim for a previously paid
				prescription in which the time period between claims is less than or equal to
				two times the days supply reported by the previously paid Senior Gold claim for
				the same prescription. A Refill Prescription Claim may have the same or
				different prescription number.
3.
				For Senior Gold claims with service dates on or after the initiation of the
				program, the following days supply limitations shall apply:
i. The days supply limitation for an Initial
				Prescription Claim shall be limited to a 34-day supply.
ii. The day supply limitation for a Refill
				Prescription Claim shall be limited to a 34-day supply or 100 dosage units,
				whichever is greater.
4.
				When Senior Gold is the secondary payer to the Medicare Prescription Drug
				Program, any days supply standards required pursuant to the Medicare
				Prescription Drug, Improvement and Modernization Act of 2003,
				Pub. L.
				108-173, effective December 8, 2003 and the rules
				promulgated thereunder at
				42 CFR §
											423.1 et seq., shall supersede the
				requirements set forth in
				10:167C-1.14.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.15 - Dosage and directions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Dosage and
				directions for use shall be indicated on all prescriptions. Prescriptions
				written and dispensed with no specific directions, such as "Prn," "as directed"
				or "ad lib," etc. are not eligible for reimbursement. Specific directions such
				as "1 tablet 4 times a day PRN" are required.
1. Exceptions:
i. Topical preparations including ophthalmic
				and optic drops and ointments;
ii.
				Nitroglycerin;
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.16 - Telephone-rendered original prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Telephone
				orders from prescribers for original prescriptions shall be permitted in
				accordance with all applicable Federal and State laws and
				regulations.
(b) For purposes of
				reimbursement, telephone authorization to refill an original prescription with
				no refill remaining is considered a new order and requires a new written
				prescription with a new prescription number. Stamping or writing a new number
				on the original prescription order does not constitute a new prescription under
				the Program.
(c) When a prescriber
				chooses not to allow product interchange on a telephone order, the statement
				"Substitution not permitted by prescriber-telephoned RX" plus the pharmacist's
				full signature next to or below the statement, shall appear on the prescription
				order. A rubber stamp bearing the statement is acceptable.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.17 - Changes or additions to the original prescription

Current through Register Vol. 56, No. 14, July 15, 2024
Changes or additions to the original prescription, when
				  approved by the prescriber, shall be clearly indicated (including date and
				  time) and signed by the dispensing pharmacist. No changes (for example, dosage,
				  quantity, number or refills, days supply, etc.) are permitted on the original
				  prescription order after the claim is submitted for payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.18 - Prescription refill

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The provider
				shall submit a properly completed claim form or electronic claim in the proper
				EMC claim format to the fiscal agent for reimbursement of an allowable refill.
				An allowable refill shall comply with the following instructions in order to be
				reimbursed as such:
1. Refill instructions
				must be indicated in writing by the prescriber on the original prescription or
				verbally when telephoning the original prescription to the pharmacist. Verbal
				instructions shall be reduced to writing by the pharmacist, in accordance with
				45:14-14.
2. The original prescription is valid for the
				12-month period beginning with the date of the original prescription. There is
				no limit to the number of refills dispensed during the 12-month period.
i. Exception: Oral contraceptives originally
				prescribed for three ovulatory cycles may be refilled up to three times within
				one year if so indicated by the prescriber on the original
				prescription.
3. A
				telephone authorized refill for a prescription with no refill remaining must be
				assigned a new prescription number.
4. Prescription refills shall not be
				dispensed until a reasonable quantity (approximately 85 percent) of the
				medication originally dispensed or refilled could have been consumed in
				accordance with the prescriber's written directions for use.
i. Exception: When a prescription is lost or
				destroyed, requiring a replacement prescription to be dispensed before the
				original prescription could have been consumed in accordance with the
				prescriber's written directions for use, and original pharmacy claim with
				written justification must be submitted to the fiscal agent for payment
				consideration.
5. When
				Senior Gold is the secondary payer to the Medicare Prescription Drug Program,
				any days supply standards required pursuant to the Medicare Prescription Drug,
				Improvement and Modernization Act of 2003,
				Pub. L.
				108-173, effective December 8, 2003 and the rules
				promulgated thereunder at
				42 CFR §
											423.1 et seq. shall supersede the
				requirements set forth in
				10:167C-1.18.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.20 - Drug efficacy study implementation (DESI)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Less than
				effective drugs" are subject to a Notice of Opportunity for Hearing (NOOH) by
				the Food and Drug Administration (FDA).
1.
				Reimbursement is not available for the purchase or administration of any drug
				product that meets all of the following conditions:
i. The drug product was approved by the Food
				and Drug Administration (FDA) before October 10, 1962;
ii. The drug product is available only
				through prescription;
iii. The drug
				product is the subject of a notice of opportunity for hearing issued under
				Section 505(e) of the Federal Food Drug, and Cosmetic Act and published in the
				Federal Register on a proposed order of FDA to withdraw its approval for the
				drug product because it has determined that the product is less than effective
				for all its labeled indications; and
iv. The drug product is presently the subject
				of an efficacy review study performed by FDA (see
				21
				CFR 310.6 including all subsequent amendments
				and supplements). The FDA efficacy review potentially can determine
				justification for a drug product's medical need. If a drug product fails this
				review, the product is classified as a drug efficacy study implementation
				(DESI) drug.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.21 - Bundled drug service

Current through Register Vol. 56, No. 14, July 15, 2024
(a) "Bundled drug
				service" means a drug or service that is marketed or distributed by the
				manufacturer or distributor as a combined package which includes in the cost
				the drug product and ancillary services such as, but not limited to, case
				management services and laboratory testing.
(b) Bundled drug service shall not be
				eligible for reimbursement by the Senior Gold program. The cost of the drug
				product which is a component of a bundled drug service (see
				10:167C-1.12, Covered
				pharmaceutical services) shall be covered by the Senior Gold program.
1. In order to determine eligibility for
				reimbursement, manufacturers or distributors of a bundled drug service shall
				submit complete product information, including the cost to the Program of the
				drug product component of the bundled drug service, and other information as
				requested by the Department to the Commissioner, Department of Human Services,
				PO Box 700, Trenton, New Jersey 08625-0700.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167C - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE SENIOR GOLD PROGRAM › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167C-1.22 - Claim submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An approved
				pharmacy provider may choose to:
1. Submit a
				properly completed hard copy pharmacy claim form approved by the New Jersey
				Division of Medical Assistance and Health Services (DMAHS);
2. Submit an electronic media claim (EMC) by
				modem, diskette or magnetic tape in an electronic format approved by DMAHS.
i. In order for a pharmacy provider to be
				eligible to submit an EMC claim to the Medicaid and/or programs, a pharmacy
				provider or vendor of EMC services shall complete the "New Jersey Medicaid
				Provider Electronic Billing Agreement."
ii. The completed agreement shall be
				submitted to the fiscal agent and approved by the Division of Medical
				Assistance and Health Services.
iii. The pharmacy provider or vendor of EMC
				services shall submit electronic media claims under an approved submitter
				identification number and comply with EMC requirements contained in the
				N.J.A.C. 10:51, Appendix E, incorporated herein by reference.
iv. For the purposes of this subchapter, all
				electronically submitted claims, including POS claims, shall commonly be
				referred to as EMC claims; or
3. Enter into an agreement with a
				point-of-sale (POS) intermediary or directly provide a similar
				telecommunication network approved by DMAHS to submit claims to the fiscal
				agent for adjudication. POS claims require an electronic format which complies
				with the National Council Prescription Drug Program standard, Version 3.2, as
				amended and supplemented, incorporated herein by reference. The Council's
				address is 4201 North 24th Street, Suite 365 Phoenix, Arizona 85016.
i. The approved POS intermediary or provider
				established network shall enter into an agreement with the State of New Jersey
				to provide on-line telecommunication services, including transmission of
				pharmacy claim detail data, access to the fiscal agent's POS computer and
				return of adjudicated claim data to the provider.