N.J. Admin. Code § 10:51-1.14

Current through Register Vol. 56, No. 24, December 18, 2024

Section 10:51-1.14 - Services requiring prior authorization

(a) The provider shall obtain prior authorization, when required by this chapter, by phone or in writing, from the professional staff of the Division's prior authorization agent for pharmacy services. The pharmacy prior authorization agent is available at a toll-free telephone number 24 hours a day, seven days a week. When a form is required by this chapter, the appropriate form that must be used to request prior authorization is indicated in the Fiscal Agent Billing Supplement. Information on the form is transmitted, on-line, from the pharmacy prior authorization agent to the fiscal agent who, in turn, confirms the status of the authorization request by mail and provides the specific prior authorization number.

1. In an administrative emergency (see N.J.A.C. 10:49-6.1(b)3 ) when the pharmacy prior authorization agent is unavailable, the provider may dispense a 72 hour supply of the prescribed drug.

i. If the drug is to be continued beyond 72 hours, and the pharmacy prior authorization agent is unavailable, the provider may dispense a total of a five day's supply. If the drug is to be continued either beyond the 72 hours or five days period, the provider shall hold the claim and obtain prior authorization for the balance of the prescription when the pharmacy prior authorization agent is available during normal business hours.

(b) The following drugs and specific therapeutic classes require prior authorization:

1. Enteral nutritional products and special infant formulas may only be authorized when medically necessary and when not available from the Women, Infants and Children (WIC) Nutritional program;

i. Medically necessary enteral nutritional products for treatment of beneficiaries, which may be administered orally, via naso-gastric tube, gastrostomy tube or needle catheter jejunostomy must be prior authorized. Special liquid or powdered diets for treatment of obesity or regular infant formulas are not considered enteral nutritional products;

ii. Electrolyte replacement supplements are not considered enteral nutritional supplements and do not require prior authorization.

2. Methadone (not eligible for reimbursement when used for drug detoxification or for addiction maintenance);

3. Drugs available only for treatment through an Investigational New Drug (IND) application;

4. Anorexiants and antiobesics when used for the treatment of conditions approved by the New Jersey State Board of Medical Examiners at N.J.A.C. 13:35-6.7;

5. Lipase inhibitors, used in the treatment of obesity, as follows:

i. The provider shall telephone the pharmacy prior authorization agent, using the toll-free telephone number supplied by the Division. Pharmacy prior authorization is available 24 hours a day, seven days a week. The pharmacy prior authorization agent reviews the information provided and automatically prior-authorizes a 30-day supply. Subsequent authorizations are based on criteria established by the New Jersey Drug Utilization Review Board, as specified in ii below.

ii. The lipase inhibitors will be provided for an initial 30-day period. A prior authorization will be issued without clinical criteria for an initial prescription for a maximum 30-day supply. During this initial 30-day period, the pharmacy prior authorization agent will contact the physician to request justification for continuing the use of the lipase inhibitor. If justification is received by the pharmacy prior authorization agent, the lipase inhibitor will be prior authorized for an additional 30-day supply. After these two 30-day periods, any subsequent provision of lipase inhibitors shall not be dispensed without prior authorization. Such subsequent prior authorizations for lipase inhibitors shall be limited to 90-day supply; and

6. Any prescription claim for the same beneficiary, provided within the same calendar month, that exceeds the monthly prescription volume threshold of 12 prescriptions per month. This applies whether the prescriptions were dispensed by one or more pharmacies. The need for prior authorization shall be communicated to providers via the point of sale claims processing system. Prior authorization shall be requested as required by (a) above, except that prior authorization shall not be required in the following circumstances:

i. Pharmaceutical services provided to Medicaid beneficiaries residing in a nursing facility, assisted living residence, comprehensive personal care home, or residential health care facility;

ii. Certain drugs and specific therapeutic drug classes including clozapine, antihemophiliac drugs, immunosuppressants, and HIV/AIDS drugs (limited to protease inhibitor, antiretroviral drugs, nucleoside analogs and reverse transcriptase inhibitors);

iii. Certain legend drugs, including oral contraceptives, ophthalmic preparations, otic preparations, nitroglycerin patches, vaginal preparations, and hemorrhoidal preparations;

iv. Drugs otherwise requiring prior authorization in accordance with this subsection;

v. Drugs otherwise requiring prior authorization by the Work First New Jersey/General Assistance program; and

vi. Drugs dispensed to beneficiaries in the pharmacy lock-in program.

N.J. Admin. Code § 10:51-1.14

Amended by 48 N.J.R. 2785(a), effective 12/19/2016