N.J. Admin. Code § 10:167C-1.13

Current through Register Vol. 57, No. 1, January 6, 2025
Section 10:167C-1.13 - Non-covered pharmaceutical services
(a) The following classes of prescription drugs or conditions are not covered under the Senior Gold 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 over the counter diabetic testing materials; insulin; and insulin needles and/or syringes;
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 N.J.A.C. 10:167C-1.20);
13. Any bundled drug service, except drug product cost which is a component of a bundled drug service (see N.J.A.C. 10:167C-1.21);
14. Preventive vaccines, biological and therapeutic drugs distributed to hospital clinics and/or community health centers by the New Jersey Department of Health and Senior Services;
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; and
16. Electronic monitoring devices.
(b) Otherwise reimbursable products shall be excluded from payment, under the following condition(s):
1. Products whose costs are found to be in excess of defined costs outlined in N.J.A.C. 10:167C-1.5, Basis of payment;
2. Covered diabetic testing materials, which do not offer significant price and/or therapeutic advantage. The criteria shall be cost and improvement in accuracy over existing reimbursable products. Therapeutic advantage (in the case of diabetic testing materials, improvement in accuracy) shall be determined by evaluation of literature and/or cost effectiveness data submitted in support of a request for admission of a diabetic testing material for inclusion in the list of reimbursable products;
3. Drug products available in unit-dose packaging and dispensed to residents in a boarding home or residential care setting or other community-type setting. Other community-type setting shall not include certain assisted living settings, including assisted living residency (ALRs), comprehensive personal care homes (CPCHs) and alternative family care (AFC) homes licensed by the Department of Health;
4. A prescription refilled too soon as described in N.J.A.C. 10:167C-1.18(a) 5;
5. Drug products denied payment based on point-of-sale (POS) and prospective drug utilization review (PDUR) standards adopted by the Senior Gold program. (see N.J.A.C. 10:167C-1.26); and
6. Cosmetic drugs including drugs used in the treatment of baldness, age spots and weight loss unless medically necessary. The Medical Exception Process (MEP) specified at N.J.A.C. 10:167C-1.27 shall be followed to confirm medial necessity.
(c) Manufacturers and distributors may request the review of a denial of reimbursement for products under (b) above by providing supportive information to previously submitted, within 30 days of the date of the denial. Agency decisions after review of support material is final.

N.J. Admin. Code § 10:167C-1.13