N.J. Admin. Code § 10:167C-1.4

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

Section 10:167C-1.4 - Program restrictions affecting payment for prescribed drugs

(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. However, the prescriber's discretion is limited for certain drugs. Reimbursement may be denied if the requirements of the following rules are not met:

1. Covered and non-covered pharmaceutical services as listed in N.J.A.C. 10:167C-1.12 and 1.13, respectively;

2. Quantity of medication (see N.J.A.C. 10:167C-1.14);

3. Pharmaceutical services requiring pharmacist intervention as part of the Senior Gold Prospective Drug Utilization Review (PDUR) program (see N.J.A.C. 10:167C-1.26);

4. Dosage and directions (see N.J.A.C. 10:167C-1.15);

5. Telephone rendered original prescriptions (see N.J.A.C. 10:167C-1.16);

6. Changes or additions to the original prescription (see N.J.A.C. 10:167C-1.17);

7. Prescription refill (see N.J.A.C. 10:167C-1.18);

8. Prescription Drug Price and Quality Stabilization Act (N.J.S.A. 24:6E-1 et seq.) (see N.J.A.C. 10:167C-1.19);

i. Products listed in N.J.A.C. 8:71, distributed to all prescribers and pharmacists; and

ii. Non-proprietary or generic dispensing (see N.J.A.C. 10:167C-1.10);

9. Federal regulations ( 42 CFR 447.301, 331 - 333) that set the aggregate upper limits on payment for certain multi-source drugs if Federal Financial Participation (FFP) is to be made available. The limit applies to all "maximum allowable costs" (MAC) drugs (see N.J.A.C. 10:167C-1.5, basis of payment);

10. Drug Efficacy Study Implementation (DESI); "Less than effective drugs" subject to a Notice of Opportunity for Hearing (NOOH) by the Federal Food and Drug Administration (see N.J.A.C. 10:167C-1.20 and listing of DESI drugs in N.J.A.C. 10:51, Appendix A); and

11. Brand name prescription drugs shall be dispensed pursuant to the requirements for prior authorization set forth in the Fiscal Year 2007 Appropriations Act, P.L. 2006, c. 45, as amended and supplemented by subsequent State appropriations acts.

N.J. Admin. Code § 10:167C-1.4

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