reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.7 - Basis of payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Subject to the requirements of the annual
				State appropriations act, this section provides a summary of the elements
				involved in the calculations 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 10:167A-1.6;
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). The drug price shall not exceed the lower of the average
				wholesale price minus 10 percent as supplied by the reference drug file
				contractors; 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 meet the criteria specified in
				10:167A-1.14, Covered
				pharmaceutical services.
3. Federal regulations (
				42 CFR
				447.512 through 514 ) that set the aggregate
				upper limits on payment for certain covered drugs in the pharmaceutical
				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 or insulin needles and
				syringes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.8 - Reserved

Current through Register Vol. 56, No. 14, July 15, 2024
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.9 - Prescription drug dispensing fee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The dispensing
				fee for each prescription dispensed to recipients by providers having retail
				permits, and where PAAD is the primary payer is $ 3.73 to $ 3.99. Additional
				dispensing fees (add-ons) per prescription shall be given, when PAAD is the
				primary payer, 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 PAAD beneficiaries opportunities to
				utilize this service.
2. Impact
				area location: $ 0.15. The provider shall have a combined Medicaid and PAAD
				primary prescription volume, as calculated by DMAHS, 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 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.10 - PAAD program copayment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Beneficiaries
				in the PAAD program are responsible for a part of the cost of drugs and devices
				covered by the PAAD program. At the point of sale, a PAAD beneficiary shall
				render to a pharmacy provider a fixed or adjustable copayment of an amount
				determined appropriate by the Legislature (see
				10:167A-1.21(a)4 
				).
(b) A copayment shall be
				rendered to a pharmacy provider for each original or refill prescription
				dispensed. The provider's usual and customary charge billed to the PAAD program
				shall be inclusive of the copayment amount which will be deducted by the New
				Jersey Medicaid Management Information System (NJMMIS).
1. Under no circumstances is the required
				rendered copayment amount to be waived for reasons of promotion, advertisement
				and/or competitive considerations. Failure to comply with PAAD program
				copayment requirements may result in a suspension of a provider's approval to
				participate in the PAAD program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.11 - Compounded prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Compounded
				prescriptions may be reimbursed by the PAAD program. Compounded prescriptions
				are extemporaneously prepared mixtures of an active ingredient or ingredients
				and are dispensed by approved providers.
(b) Claims for compounded prescriptions shall
				be electronically submitted to the fiscal agent through a point-of-sale (POS)
				claim adjudication system approved by the PAAD program. (See
				N.J.A.C.
				10:167A-1.27 ).
1. A compounded prescription is indicated by
				the provider by the use of the "compound drug" indicator field in the EMC claim
				format.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.12 - 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 the list of interchangeable drug products. The labeler code, drug product
				  code, and package size code of the actual product dispensed must be reported on
				  the claim form.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.13 - Provider$DQ$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
				10:167A-1.7, Basis of
				payment).
(b) The usual and
				customary charge to the PAAD 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 PAAD
				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 PAAD 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 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.14 - 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
				PAAD programs, and billed to the fiscal agent using the NCPDP claim format
				available at
http://www.njmmis.com/downloadDocuments/NJ_D-0_NCPDP_Payer_Sheet.pdf
.
(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.
2. Non-legend drugs,
				as follow:
i. Insulin needles and/or
				syringes;
ii. Insulin;
				and
iii. Syringes and needles for
				injectable medicines.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.15 - 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 PAAD
				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 insulin; insulin needles and/or syringes; and syringes and needles
				for injectable medicines for the treatment of multiple sclerosis;
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
				10:167A-1.22 );
13. Any bundled drug service,
				except drug product cost which is a component of a bundled drug service (see
				10:167A-1.23 );
14. Preventive vaccines, biologicals, and
				therapeutic drugs distributed to hospital clinics and/or community health
				centers by the New Jersey Department of Health;
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;
16.
				Diabetic testing materials;
17.
				Vitamins;
18. Cough and/or cold
				medications;
19. Drugs used for the
				treatment of erectile dysfunction;
20. Drugs used for alopecia, hair removal or
				hair restoration, eyelash growth, weight loss, and skin conditions;
				and
21. Active pharmaceutical
				ingredients, bulk drug substances, and excipients that are not a covered
				outpatient drug as defined in the Social Security Act at
				42 U.S.C. §
											1396r-8(k)(2).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.16 - Quantity of medication

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Days supply
				limitations for an Initial Prescription Claim for PAAD beneficiaries shall be
				different from days supply limitations for a Refill Prescription Claim.
1. As used in this section, "Initial
				Prescription Claim" shall mean a PAAD 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 PAAD claim with a service
				date that has exceeded two times the day's supply reported by the previously
				paid PAAD claim for the same prescription.
2. As used in this section, "Refill
				Prescription Claim" shall mean a PAAD 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 PAAD claim for the same
				prescription. A Refill Prescription Claim may have the same or different
				prescription number.
3. For PAAD
				claims where PAAD is the primary payer, 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;
				and
ii. The days supply limitation
				for a Refill Prescription Claim shall be limited to a 34-day supply or 100
				dosage units, whichever is greater.
4. PAAD shall accept the days supply
				limitations of other primary payers, including, but not limited to
				Medicare.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.17 - 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 otic drops and ointments;
ii.
				Aerosol inhalers; and
iii.
				Nitroglycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.18 - Telephone-rendered, faxed or electronically transmitted original prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Telephone,
				facsimile or electronically transmitted 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-rendered or faxed 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 PAAD program.
(c) When a prescriber chooses not to allow
				product interchange on a telephone-rendered or faxed 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.
(d) Electronically transmitted prescriptions
				shall be in compliance with the State Board of Pharmacy requirements at
				13:39-7.11.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.19 - 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 of 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 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.20 - Prescription refill

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The provider shall submit an 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 shall be indicated in
				writing by the prescriber on the original prescription, on a facsimile of the
				prescription, in the electronic prescription, or verbally when telephoning the
				original prescription to the pharmacist. Verbal instructions shall be reduced
				to writing by the pharmacist.
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. Refill instructions indicating "refill
				prn" or indicating more than five refills, shall be subject to the limits
				imposed in (a)2 above, and shall be reimbursed up to these limits
				only.
4. An authorized refill for a
				prescription with no refill remaining must be assigned a new prescription
				number.
5. Prescription refills
				shall not be dispensed until 85 percent of the medication originally dispensed
				or refilled could have been consumed in accordance with the prescriber's
				written directions for use.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.21 - Prescription Drug Price and Quality Stabilization Act

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Prescription Drug Price and Quality Stabilization Act,
				N.J.S.A.
				24:6E-1 et seq., shall apply to the PAAD
				program. This law requires that every prescription blank contain the statements
				"Substitution Permissible" and "Do Not Substitute." The prescriber shall
				initial one of the statements in addition to signing the prescription blank.
1. When the prescriber does not initial
				"Substitution Permissible" or the "Do Not Substitute" statement on a
				prescription for a drug product, the pharmacist shall substitute from the list
				of interchangeable products and bill PAAD accordingly.
2. When the prescriber initials "Substitution
				Permissible," the pharmacist shall dispense and bill PAAD for one of the less
				expensive products listed as an interchangeable drug product with the brand
				name prescribed.
3. When the
				prescriber orders by generic name, the pharmacist shall dispense the least
				expensive, therapeutically effective product available to him or her at the
				time of dispensing. The product is not required to be from the list of
				interchangeable products.
4.
				Whenever the prescriber does not specify that substitution is not permitted and
				an interchangeable drug product is available for the prescription written, the
				PAAD program shall reimburse the pharmacy only for the maximum allowable cost
				of the interchangeable product, less the PAAD program co-payment.
i. For non-MAC drugs (see
				N.J.A.C.
				10:167A-1.7 ), when the prescriber initials
				"Do Not Substitute," the pharmacist shall indicate the prescriber's preference
				by indicating "Medical Certification" in the EMC claim format and shall
				dispense and bill PAAD for the prescribed product. Reimbursement will be in
				accordance with
				N.J.A.C.
				10:167A-1.7 (see N.J.A.C. 10:51, Appendix D,
				incorporated herein by reference, Fiscal Agent Billing Supplement for
				instructions about the claim form or N.J.A.C. 10:51, Appendix E, incorporated
				herein by reference, regarding the proper EMC claim format); or
ii. For MAC drugs and in those situations in
				which a prescriber authorizes, in accordance with (b) below, the dispensing of
				a brand drug, the pharmacist shall indicate the prescriber's preference by
				indicating "Medical Certification" in the EMC claim format and shall dispense
				and bill PAAD for the prescribed product. Reimbursement will be in accordance
				with N.J.A.C. 10:167A-1.7 (see N.J.A.C.
				10:51, Appendix D, incorporated herein by reference, Fiscal Agent Billing
				Supplement for instructions about the claim form or N.J.A.C. 10:51, Appendix E,
				incorporated herein by reference, regarding the proper EMC claim
				format).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.22 - 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 NOOH issued under Section 505(e) of the Federal
				Food, Drug, and Cosmetic Act and published in the Federal Register on a
				proposed order of the 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 DESI drug.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.23 - 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 PAAD program. The cost of the drug product
				which is a component of a bundled drug service (see
				N.J.A.C.
				10:167A-1.14, Covered Pharmaceutical
				Services) shall be covered by the PAAD program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.24 - Claim submission

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An approved pharmacy provider shall enter
				into an agreement with a point-of-sale (POS) intermediary in accordance with
				the requirements of
				N.J.A.C.
				10:167A-1.27 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 EMC National Council Prescription Drug Program standards.
1. 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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.25 - Eligible PAAD beneficiary

Current through Register Vol. 56, No. 14, July 15, 2024
(a) An applicant
				shall be determined to be eligible for Pharmaceutical Assistance to the Aged
				and Disabled only if physically present in New Jersey at the time of
				application and utilization, in accordance with the provisions of N.J.A.C.
				10:167.
1. Benefits shall not be payable for
				patients in nursing facilities, hospitals or special hospitals by the PAAD
				program during any period recipients are covered for drug benefits by Medicaid,
				Medicare, Blue Cross and Blue Shield of New Jersey, Inc., or other insurance
				benefits or if such benefits are covered in the daily rate of the
				facility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.26 - PAAD beneficiary identification

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Pharmacies
				should verify that the beneficiary is a PAAD covered person. This is done by
				checking the beneficiary's PAAD identification card.
(b) The PAAD program shall issue to all PAAD
				eligibles a Validation Identification Card. The document shall contain the
				patient's name, PAAD identification number, effective date, and expiration
				date.
(c) The beneficiary is
				eligible only for the period of time indicated on the identification
				card.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.27 - Point-of-sale (POS) claims adjudication system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) PAAD
				pharmacy claims shall be submitted through a POS system and adjudicated by the
				State's fiscal agent on-line and in real-time. The pharmacist shall be required
				to enter pharmacy claim detail data into a computer or POS device and transmit
				this data to the fiscal agent over a dedicated telephone line. Regardless of
				the method of claim submission, all claims will go through all New Jersey
				Medicaid Management Information System (NJMMIS) claims processing edits and the
				claims will be processed to determine their payment disposition (for example,
				paid or denied).
1. Pharmacy services
				provided to nursing facility and residential care residents utilizing 24 hour
				unit-dose or modified unit-dose delivery systems are precluded from the POS
				system.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.28 - Prospective drug utilization review (PDUR) program

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division of
				Medical Assistance and Health Services of the Department of Human Services and
				the Department of Health have established a prospective drug utilization review
				(PDUR) program to assist pharmacy providers in monitoring drug utilization by
				PAAD beneficiaries. As a component of the PAAD point-of-sale (POS) claims
				adjudication system, the State's fiscal agent will review drug utilization
				based on claims submitted on-line and provide pharmacists with responses in
				real-time regarding utilization within PDUR standards as recommended by the
				Drug Utilization Review (DUR) Board and approved by the Department. Similar
				responses related to electronic media claims (EMC) or paper claims processed by
				the New Jersey Medicaid Management Information System (NJMMIS) shall be
				received by pharmacies on the Remittance Advice statement.
1. PDUR standards developed by the DUR Board
				shall be based on official compendia and accepted medical literature and shall
				include, but not be limited to, those standards established by First Data Bank
				(FDB) as part of the FDB DUR information system. The FDB standards are
				incorporated herein by reference and may be obtained from First Data Bank, The
				Hearst Corp., 1111 Bayhill Drive, San Bruno, CA 94066.
2. PDUR standards shall be applied to all
				PAAD pharmacy claims, regardless of the mode of claim submission.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.29 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy
				claims with service dates on or after May 3, 1999, that exceed DUR Board
				standards, the PAAD program shall utilize the medical exception process (MEP)
				to allow the override of a claim denial, when medically necessary.
1. The MEP may be administered by a vendor on
				behalf of the Department.
2. All
				pharmacy claims shall be subject to the MEP regardless of claims media, except
				that claims from long-term care facility providers shall be exempt from the
				PDUR and MEP until notice is issued otherwise.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167A - PROVISION OF PHARMACEUTICAL SERVICES UNDER THE PHARMACEUTICAL ASSISTANCE TO THE AGED AND DISABLED PROGRAM (PAAD) › Subchapter 1 - REQUIREMENTS FOR PROVISION OF PHARMACEUTICAL SERVICES › Section 10:167A-1.30 - Drug rebate program

Current through Register Vol. 56, No. 14, July 15, 2024
Reimbursement for legend drugs shall be limited to
				  manufacturers who have entered into a PAAD rebate agreement, including an
				  agreement to pay rebates on claims for which PAAD is a secondary payer, with
				  the Department of Human Services through the Division of Medical Assistance and
				  Health Services pursuant to
				  N.J.A.C.
				  10:51-1.22.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 1 - INTRODUCTION › Section 10:167B-1.1 - Purpose and intent

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 prescribed drugs.
(b)
				This manual has been developed as a statement of policy and procedures and
				addresses eligibility for the Senior Gold Prescription Discount
				Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 1 - INTRODUCTION › Section 10:167B-1.2 - Legal authority

Current through Register Vol. 56, No. 14, July 15, 2024
These rules are promulgated under the authority of the
				  Senior Gold Prescription Discount Act,
				  P.L.
				  2001, c. 96.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167B-3.1 - Department of Human Services

Current through Register Vol. 56, No. 14, July 15, 2024
The Department is the administrative unit of the State
				  government which has control over the administration of Senior Gold. Under the
				  terms of the Senior Gold Prescription Discount Act, this Department is
				  responsible for the general policies governing administration of Senior Gold
				  and for implementing the Senior Gold Prescription Discount Act through the
				  issuance of regulations in accordance with the Administrative Procedure Act.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167B-3.2 - Division of Aging Services

Current through Register Vol. 56, No. 14, July 15, 2024
The Division of Aging Services is the administrative unit
				  within the Department that processes applications, determines eligibility,
				  answers inquiries, mails eligibility cards and performs other administrative
				  functions for, or in conjunction with, the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 3 - ADMINISTRATIVE ORGANIZATION › Section 10:167B-3.3 - Senior Gold Prescription Discount Program

Current through Register Vol. 56, No. 14, July 15, 2024
The Senior Gold Prescription Discount Program in the Office
				  of Support Services for the Aged within the Department, has the direct
				  responsibility for the processing of eligibility applications from
				  applicants.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167B-4.1 - Statutory limitations

Current through Register Vol. 56, No. 14, July 15, 2024
By statute, the Senior Gold Prescription Discount Program is
				  limited to payment or reimbursement to pharmacies for the reasonable cost of
				  prescription drugs for eligible persons which exceeds the co-payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167B-4.2 - Principles of reimbursement to participating pharmacies

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order to
				become an approved provider, a pharmacy must file an application and agreement
				of participation which must be approved by the Division of Medical Assistance
				and Health Services of the Department of Human Services.
(b) No reimbursement will be made to an
				unlicensed pharmacy or to a pharmacy located in another state or
				country.
(c) Reimbursement on
				behalf of Senior Gold beneficiaries will be made directly to the participating
				pharmacies and will be for the reasonable cost (as determined by the
				Commissioner) of the prescription drugs which exceeds the co-payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167B-4.3 - Amounts of reimbursement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Program
				shall provide a payment to a pharmacy that is participating in the Program for
				the reasonable cost of one or more prescription drugs purchased by an eligible
				person who presents an identification card issued by the program in an amount
				that exceeds the co-payment paid by the eligible person.
(b) At the time of each purchase of a
				prescription drug, the eligible person shall pay a co-payment to the
				participating pharmacy that shall not be waived, discounted or rebated in whole
				or in part, and shall be equal to:
1. $ 15.00
				plus 50 percent of the remaining amount of the reasonable cost for the
				prescription drug, or the reasonable cost for the drug, whichever is less;
				or
2. $ 15.00, or the reasonable
				cost for the drug, whichever is less, in the case of an eligible person who has
				incurred out-of-pocket expenditures, including co-payments and deductibles, for
				the purchase of prescription drugs, which are not reimbursable by any other
				plan of assistance or insurance and are credited to that person's account in
				the following amounts: $ 2,000 annually for a single person and $ 3,000
				annually for a married couple. These amounts shall be incurred on or after the
				date that the person received proof of eligibility for the program from the
				Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167B-4.4 - Interchangeable drug products

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Whenever any
				interchangeable drug product contained in N.J.A.C. 8:71 is available for the
				prescription written, the Program shall reimburse only for the reasonable cost
				of the interchangeable product less the Senior Gold co-payment unless the
				prescriber specifies that substitution is not permitted.
(b) For certain brand name products as
				specified at
				10:51-1.5(b), the
				prescriber writes the statement "Brand Name Medically Necessary" on the
				prescription form.
1. If the prescriber fails
				to specify that substitution is not permissible, the Senior Gold beneficiary
				has two options:
i. To purchase an
				interchangeable drug product which is equal to or less than the maximum
				allowable cost, at the Senior Gold co-payment; or
ii. To purchase the prescribed drug product
				which is higher in cost than the maximum allowable cost and pay the difference
				between the two, in addition to the copayment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 4 - SCOPE OF SERVICE › Section 10:167B-4.5 - Beneficiary co-payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) No direct
				payment to beneficiaries will be made under the Senior Gold Program except as
				noted in (b) below. The beneficiary must pay the pharmacy a non-refundable
				Senior Gold co-pay per prescription drug.
(b) In the event that a beneficiary receives
				his or her eligibility identification card later than 30 days from the date
				that his or her complete and valid eligibility application was received by the
				Program, he or she may be eligible to receive direct reimbursement for
				prescription drugs purchased.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.1 - General provisions

Current through Register Vol. 56, No. 14, July 15, 2024
The application process includes all activity relating to a
				  request for eligibility determination. It begins with the receipt by the
				  Department of an eligibility application and continues in effect until there is
				  an official disposition of the request by the Department.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.2 - Authorized agent

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In those
				instances where the applicant is incompetent or incapable of filing an
				eligibility application on his or her own behalf, the Department shall accept
				any one of the following for the purpose of initiating such application:
1. Power of attorney;
2. A close relative by blood or marriage;
				that is, parent, spouse, son, daughter, brother, or sister;
3. A representative payee designated by the
				Social Security Administration;
4.
				A staff member of a public or private social service agency, of which the
				person is a client, who has been designated by the agency to so act;
				or
5. A friend.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.3 - Eligibility effective date

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Senior Gold
				eligibility effective date for an initial Senior Gold applicant, who meets all
				the Senior Gold eligibility criteria, is the date when a valid and complete
				eligibility application is approved by the Program.
(b) The Department shall conduct periodic
				reassessments of the eligibility of Senior Gold beneficiaries. Generally,
				renewals of eligibility shall be conducted every year.
1. Beneficiaries are required to reapply
				annually and must submit a valid and completed renewal application 45 days
				prior to their expiration date to insure that their Senior Gold benefits
				continue uninterrupted; however, if beneficiaries are late in submitting their
				valid and completed renewal applications, but file a valid and completed
				renewal application within 90 days after the expiration date, their Senior Gold
				benefits will continue uninterrupted. If a beneficiary submits a renewal
				application more than 90 days after the expiration date, the eligibility
				effective date will be the date when a valid and completed renewal application
				is processed by the Program. If the beneficiary is late in filing his or her
				renewal application by more than 90 days after the expiration date, the Program
				shall not make reimbursement until the new eligibility period has been
				established.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.4 - Exceptions from normal standards

Current through Register Vol. 56, No. 14, July 15, 2024
(a) There may be
				exceptional cases where the processing of an eligibility application cannot be
				completed within a normal 30-day period. Where substantially reliable evidence
				either of eligibility or ineligibility is still lacking, the application shall
				be continued in pending status. In each such case, however, the Department
				shall be prepared to demonstrate that the delay resulted from one of the
				following:
1. Circumstances wholly within the
				applicant's control;
2. A
				determination to afford to an applicant whose proof of eligibility has been
				inconclusive, further opportunity to develop additional evidence of eligibility
				before final action is taken on the application;
3. An administrative or other emergency that
				could not reasonably have been avoided; or
4. Circumstances wholly outside of the
				control of both the applicant and the Program.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.5 - Agency controls

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Department
				has the responsibility for reviewing a statistically valid representative
				sample of Senior Gold cases to assure beneficiary eligibility. A quality
				control review of sample cases selected on a random basis includes:
1. Analysis of the beneficiary's case record,
				including the application which is maintained by the PAAD Bureau;
2. An interview with the beneficiary or the
				beneficiary's representative(s) to review eligibility for Senior Gold and
				availability of third party resources; and
3. Verification of eligibility factors and
				third party liability information through collateral contacts.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 5 - APPLICATION PROCESS › Section 10:167B-5.6 - Responsibilities in the application renewal process

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Program has
				responsibility in the application process to:
1. Explain the purposes and eligibility
				requirements of the Program and indicate the applicant's rights and
				responsibilities under its provisions;
2. Process applications and
				reapplications;
3. Issue
				eligibility cards to eligible persons and to notify ineligible persons
				promptly;
4. Automatically mail
				reapplication forms approximately four months prior to the eligibility
				expiration date; and
5. Copy
				eligibility application and supporting documents onto microfilm and retain the
				microfilm for audit purposes.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 6 - ELIGIBILITY REQUIREMENTS › Section 10:167B-6.1 - Age

Current through Register Vol. 56, No. 14, July 15, 2024
(a) To be eligible
				for Senior Gold, the applicant shall be 65 years of age or older or shall be
				under 65 and over 18 years of age and receive Social Security Title II
				disability benefits. Individuals under age 65 who receive disability benefits
				on behalf of someone other than themselves are ineligible. The applicant shall
				be able to document his or her age upon request by the Department. The
				Department will require that the applicant submit a photocopy of his or her
				birth certificate or other acceptable proof of age if over 65 years of
				age.
(b) The following are
				acceptable proofs of age:
1. Primary proof:
				The applicant is required to submit a photocopy of one of the following
				documents:
i. Birth certificate;
ii. Baptismal certificate;
iii. Bris certificate;
iv. Social Security records verifying age
				(can be obtained from local Social Security office); or
v. Railroad retirement letter (can be
				obtained from Railroad Retirement Board).