New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 167B - SENIOR GOLD PRESCRIPTION PROGRAM MANUAL › Subchapter 2 - DEFINITIONS › Section 10:167B-2.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this chapter,
				  shall have the following meanings, unless the context clearly indicates
				  otherwise:
"Annual income" means all income from whatever source
				  derived, actually received or anticipated.
"Anticipated income" means the amounts of income the
				  applicant can reasonably be expected to receive during the calendar
				  year.
"Applicant" means an individual who applies for Senior Gold
				  Prescription Benefits either personally or through an authorized agent.
"Authorized agent" means a person who initiates the Senior
				  Gold Benefits application for a person who is incompetent or incapable of
				  filing the Senior Gold Benefits application on his or her behalf.
"Authorized representative" means a person with legal
				  authority to act on behalf of an individual in making decisions related to the
				  individual's enrollment in, disenrollment from, and access to negotiated prices
				  under the Medicare Prescription Drug Program.
"Beneficiary" means an individual who has been found eligible
				  for Senior Gold Prescription benefits.
"Business income" means net income derived from a business,
				  trade or profession or from the rental of property after deductions of the
				  ordinary and necessary expenses attributable to the business, trade,
				  profession, or to the rental or property which are allowed under the Federal
				  Internal Revenue Code and regulations issued thereunder.
"Calendar year" means a year beginning January 1 and ending
				  on December 31. It is the base period utilized to determine annual income and
				  Senior Gold benefits eligibility.
"Centers for Medicare and Medicaid Services" or "CMS" means
				  the agency of the Federal Department of Health and Human Services that is
				  responsible for the administration of the Medicare program in the United
				  States.
"Commissioner" means the Commissioner of the Department of
				  Human Services.
"Current year" means the calendar year in which a person
				  applies or reapplies for Senior Gold benefits.
"Department" means the Department of Human Services.
"Expiration date" means the date when a beneficiary's Senior
				  Gold benefits eligibility ends.
"Legend drug" means any approved drug product which by
				  Federal law cannot be dispensed without a prescription and bears the statement
				  of the label: "Caution: Federal law prohibits dispensing without a
				  prescription," or the symbol "RX."
"Medicare-approved prescription drug discount card program"
				  means a prescription drug discount card program as to which the sponsor thereof
				  has received Medicare approval and has entered into a contract with CMS.
"Medicare Prescription Drug Program" means the program
				  established under the Medicare Prescription Drug, Improvement, and
				  Modernization Act of 2003, Pub. L. 108-173, 117 Stat.
				  2066, approved December 8, 2003.
"Pharmaceutical assistance" means the payments authorized by
				  the Department to a participating pharmacy on behalf of a Senior Gold
				  beneficiary.
"Pharmacy" means any pharmacy located in New Jersey,
				  operating under a valid permit from the Board of Pharmacy of the State of New
				  Jersey, which has filed an application and agreement of participation which has
				  been approved by the New Jersey Medicaid Program.
"Prescription drug(s)" means all approved legend drugs,
				  including any interchangeable drug products contained in the latest list
				  approved and published pursuant to N.J.A.C. 8:71 and in conformance with the
				  provisions of the "Prescription Drug Price and Quality Stabilization Act," and
				  insulin, insulin syringes, insulin needles and certain diabetic testing
				  materials when prescribed.
1. The term "legend prescription drugs" includes:
i. Any drug product which by Federal law cannot be dispensed
				  unless ordered by a licensed prescriber;
ii. Every product considered to be a legend prescription drug
				  which is required by the Federal Food, Drug and Cosmetic Act to have the
				  following statement on the manufacturer's original packaging label: "Caution:
				  Federal law prohibits dispensing without a prescription," or the symbol
				  "RX";
iii. Insulin, insulin syringes and insulin needles. While not
				  legend drugs, these items are covered by this program when prescribed;
iv. Diabetic testing materials, including blood glucose
				  regent strips which can be visually read, urine monitoring strips, tapes and
				  tablets and bloodletting devices and lancets (electronic monitoring devices are
				  not included); and
v. Syringes and needles for injectable medicines for the
				  treatment of multiple sclerosis.
2. The term "prescription drugs" excludes cosmetic drugs as
				  indicated at
				  10:167A-1.13 unless deemed to be
				  medically necessary by a licensed prescriber.
"Previous year" means the calendar year preceding the year in
				  which the person is applying or reapplying for Senior Gold benefits. For
				  example, 2000 is the "previous year" when referring to an application which is
				  dated between January 1, 2001 through December 31, 2001, inclusive. If a person
				  who is required to submit a Federal, State and/or city income tax return
				  applies for Senior Gold benefits at the beginning of a calendar year but has
				  not yet filed an income tax return for the previous year, the last year for
				  which the person filed a tax return is considered to be the "previous year"
				  when completing the Senior Gold application.
"Program" means the Senior Gold Prescription Discount Program
				  which was created as a result of the passage of the Senior Gold Prescription
				  Discount Act,
				  P.L.
				  2001, c. 96.
"Provider" means any individual, partnership, association,
				  corporation, institution, or any other public or private entity, agency, or
				  business concern, meeting applicable requirements and standards for
				  participation in the New Jersey Medicaid Program, Pharmaceutical Assistance to
				  the Aged and Disabled Program, and the Senior Gold Prescription Discount
				  Program, and where applicable, holding a current valid license, and lawfully
				  providing medical care, services, goods and supplies authorized under
				  30:4D-1 et seq. and amendments
				  thereto.
"Reasonable cost" means the maximum allowable cost of the
				  prescription drug and shall include the conditions set forth in the Fiscal Year
				  2007 Appropriations Act,
				  P.L.
				  2006, c. 45, approved
				  July 8, 2006, as amended and supplemented by subsequent State appropriations
				  acts containing methodologies or requirements for the calculation of reasonable
				  costs under the Program.
"Resident" means "one legally domiciled within the State (of
				  N.J.) for a period of 30 days immediately preceding the date of application for
				  inclusion in the Senior Gold Program. Mere seasonal or temporary residence
				  within the State, of whatever duration, does not constitute domicile." (See
				  N.J.A.C. 10:69A-6.4 for residence requirements.)
"Senior Gold" means the Senior Gold Prescription Discount
				  Program.
"Senior Gold co-pay" means the payment to the pharmacy by the
				  eligible person that shall not be waived, discounted or rebated in whole or in
				  part.
"Special needs trust" means a trust containing the assets of
				  a disabled individual that is established for the sole benefit of the
				  individual by a parent, grandparent, legal guardian or court prior to the time
				  the individual reaches the age of 65. (See
				  10:167B-2.2 for
				  provisions).
"Viatical settlement" means the sale or cashing in of a life
				  insurance policy prior to the death of the insured, due to the fact that the
				  insured has experienced a catastrophic, life-threatening or chronic illness or
				  condition.