New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 54 - PHYSICIAN SERVICES › Subchapter 8 - PHARMACEUTICAL SERVICES › Section 10:54-8.2 - Pharmaceutical; 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 the Pharmaceutical Services chapter, 10:51-1.11 and 1.13, respectively, incorporated herein by reference;
2. Pharmaceutical services requiring prior authorization (see 10:51-1.14, incorporated herein by reference);
3. Quantity of medication (see 10:51-1.15, incorporated herein by reference);
4. Dosage and directions (see 10:51-1.16, incorporated herein by reference);
5. Telephone-rendered original prescriptions (see 10:51-1.17, incorporated herein by reference);
6. Changes or additions to the original prescription (see 10:51-1.18, incorporated herein by reference);
7. Prescription refill (see 10:51-1.19, incorporated herein by reference);
8. Prescription Drug Price and Quality Stabilization Act (24:6E-1 et seq.) (see 10:51-1.20, incorporated herein by reference).
i. Products listed in the current New Jersey Drug Utilization Review Council (DURC) Formulary, (hereafter referred to as "the Formulary"), and all subsequent revisions, distributed to all prescribers and pharmacists.
ii. Non-proprietary or generic dispensing (see 10:51-1.9, incorporated herein by reference);
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 cost" drugs (see 10:51-1.5, Basis of payment, incorporated herein by reference);
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 10:51-1.21 and listing of DESI drugs in Appendix A of N.J.A.C. 10:51, incorporated herein by reference);
11. Drug Manufacturers' Rebate Agreement with the Centers for Medicare and Medicaid Services (CMS) of the United States Department of Health and Human Services (see 10:51-1.22, incorporated herein by reference);
12. Medical exception process (MEP) (see 10:54-8.3 );
13. In addition, diabetic testing materials, including blood glucose reagent strips, urine monitoring strips, tapes, tablets and lancets. Electronic blood glucose monitoring devices or other devices used in the monitoring of blood glucose levels are considered medical supplies and are covered services by Medicaid/NJ FamilyCare. These services may require prior authorization from the Medical Assistance Customer Center (MACC) (See N.J.A.C. 10:59, Medical Supplier Services); and
14. For claims with service dates on or after July 1, 1999, the pharmacist shall be reimbursed for the least expensive, therapeutically effective nutritional supplement or specialized infant formula, at the time of dispensing unless the prescriber indicates, in his or her own handwriting on each written prescription, or follow-up written prescription to a telephone rendered prescription, the phrase "Brand Medically Necessary."