N.J. Admin. Code § 10:167B-4.4

Current through Register Vol. 56, No. 23, December 2, 2024

Section 10:167B-4.4 - Interchangeable drug products

(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.

(c) If the prescriber specifies on the prescription that substitution is not permissible, the Program will reimburse for the reasonable cost of the prescribed product less the Senior Gold co-payment pursuant to the requirements respecting prior authorization 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.

N.J. Admin. Code § 10:167B-4.4

Amended by R.2007 d.134, effective 5/7/2007.
See: 38 N.J.R. 5295(a), 39 N.J.R. 1711(a).