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-1.19 - Prescription Drug Price and Quality Stabilization Act requirements

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The
				Prescription Drug Price and Quality Stabilization Act,
				24:6E-1 et seq., shall apply to
				the 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 listed in N.J.A.C. 8:71 (see
				10:51-1.4(a)9 
				i), the pharmacist shall substitute from the list of interchangeable products
				and bill Senior Gold accordingly.
2. When the prescriber initials "Substitution
				Permissible," the pharmacist shall dispense and bill for one of the less
				expensive products listed in N.J.A.C. 8:71 as interchangeable with the brand
				name prescribed.
3. When the
				prescriber orders by generic name, the formulary does not apply. 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 that is
				listed in the latest issue of the formulary is available for the prescription
				written, the Program shall reimburse the pharmacy only for the maximum
				allowable cost of the interchangeable product, less the program
				co-payment.
5. For non-MAC drugs
				(see 10:167C-1.5 ), when the prescriber
				initials "Do Not Substitute" and requests prior authorization, the pharmacist
				shall indicate the prescriber's preference by indication "Medical
				Certification" and the prior authorization number, if required, pursuant to the
				requirements of the Fiscal Year 2007 Appropriations Act,
				P.L.
				2006, c. 45, as amended
				and supplemented by subsequent State appropriations acts, respecting prior
				authorization for dispensing drugs under the Program on the claim form or the
				similar field in the EMC claim format and shall dispense and bill Senior Gold
				for the prescribed product. Reimbursement will be the estimated acquisition
				cost (EAC), as defined in
				10:167C-1.5 (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).
6. Claims 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" and the prior
				authorization number, if required, pursuant to the requirements of the Fiscal
				Year 2007 Appropriations Act,
				P.L.
				2006, c. 45, as amended
				and supplemented by subsequent State appropriations acts, respecting prior
				authorization for dispensing drugs under the Program, on the claim form, or
				similar field in the EMC claim format and shall dispense and bill Senior Gold
				for the prescribed product. Reimbursement will be the estimated acquisition
				cost (EAC) (see
				10:167C-1.5 ) plus applicable
				dispensing fee or the usual and customary charge, whichever is less for that
				product (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).