N.J. Admin. Code § 10:167A-1.28

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:167A-1.28 - Prospective drug utilization review (PDUR) program

(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.

(b) POS participating pharmacy providers shall be required to meet the conditions described in N.J.A.C. 10:167A-1.27.

(c) In addition to POS responses related to adjudication of PAAD pharmacy claims returned to the pharmacy, pharmacists shall be notified regarding drug utilization inconsistent with adopted PDUR standards which may include, but not be limited to:

1. Drug interactions;

2. Maximum/minimum daily dosage alerts;

3. Therapeutic duplication;

4. Drug age conflicts;

5. Duration of therapy;

6. Drug-disease precautions; and

7. Drug-pregnancy precautions.

(d) The PDUR program may apply adopted standards based on a severity index approved by the Department or DUR Board to determine appropriate pharmacist intervention and/or claim disposition (for example, payment or denial) of PAAD pharmacy claims.

(e) Based on the severity of a potential PDUR conflict or interaction, pharmacists shall be required to consult with the beneficiary and/or prescriber to resolve matters indicated by PDUR messages returned by the POS system.

(f) The pharmacist intervention requirements related to the PDUR program are in addition to beneficiary interactions related to New Jersey State Board of Pharmacy requirements regarding the "offer to consult," as described in N.J.A.C. 13:39-7.14, Patient profile record system.

N.J. Admin. Code § 10:167A-1.28

New Rule, R.1996 d.146, effective 3/18/1996 (operative April 1, 1996).
See: 27 N.J.R. 4566(a), 28 N.J.R. 1526(a).
Amended by R.1998 d.464, effective 9/8/1998.
See: 30 N.J.R. 2197(a), 30 N.J.R. 3309(a).
Amended by R.1999 d.148, effective 5/3/1999.
See: 30 N.J.R. 4109(a), 31 N.J.R. 1197(b).
Recodified from N.J.A.C. 8:83C-1.26 and amended by R.2003 d. 248, effective 6/16/2003.
See: 34 N.J.R. 3456(a), 35 N.J.R. 2642(a).
Former N.J.A.C. 8:83C-1.28, Drug rebate program, recodified to N.J.A.C. 8:83C-1.30.