N.J. Admin. Code § 10:51-2.17

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:51-2.17 - Prescription Drug Price and Quality Stabilization Act

(a) The Prescription Drug Price and Quality Stabilization Act, 24:6E-1et seq., shall apply to the Medicaid and NJ FamilyCare programs. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." The prescriber shall initial one of the statements in addition to signing the prescription blank.

1. When the prescriber does not initial "Substitution Permissible" or the "Do Not Substitute" statement on a prescription or in-patient medication order for a drug product listed in the DURC Formulary, the pharmacist shall substitute from the list of interchangeable products and bill Medicaid or NJ FamilyCare accordingly.

2. When the prescriber initials "Substitution Permissible," the pharmacist shall dispense and bill Medicaid or NJ FamilyCare for one of the less expensive products listed in the DURC Formulary as interchangeable with the brand name prescribed. The Medicaid or NJ FamilyCare fee-for-service beneficiary must accept the interchangeable product unless the beneficiary is willing to pay the pharmacy's full, usual, and customary price. If that occurs, the pharmacist shall so note on the prescription blank and no claim shall be submitted to Medicaid or NJ FamilyCare.

3. When a prescriber authorizes, in accordance with (b) below, the dispensing of a brand MAC drug, the pharmacist shall indicate the prescriber's preference by indicating "Medical Certification" on the claim form or the similar field in the EMC claim format and shall dispense and bill Medicaid or NJ FamilyCare, as appropriate, for the prescribed product. Reimbursement will be the estimated acquisition cost (EAC) (see 10:51-2.5 ) plus applicable dispensing fee or the usual and customary charge, whichever is less for that product (see Appendix D, Fiscal Agent Billing Supplement for instructions about the claim form and Appendix E regarding the proper EMC claim format).

4. When the prescriber orders by the generic name, N.J.A.C. 8:71 (see 10:51-2.4 ) does not apply. The pharmacist shall dispense the least expensive, therapeutically effective product available to him or her at the time of dispensing. The product need not necessarily be from the list of interchangeable products.

(b) Federal regulations prescribe the aggregate upper limit, for which Federal Financial Participation (FFP) is available, that Medicaid or NJ FamilyCare-Plan A may reimburse for certain multi-source drugs. This limit shall also apply to NJ FamilyCare-Plans B and C. The limit shall apply to all listed MAC drugs (see Appendix B) unless the prescriber indicates in his or her own handwriting on each written prescription or in-patient medication order or follow-up written prescription or in-patient medication order to a telephone rendered prescription or technologically transmitted, the phrase "Brand Medically Necessary." The Federal regulation requires a handwritten statement and does not permit the use of alternatives such as a check off box, initials, or prescriber's signature, next to a preprinted statement "Do Not Substitute," nor does it allow a hand written statement "Do Not Substitute." For purposes of reimbursement, the physician's override capability under 24:6E-1does not apply to drugs that have a Federal MAC limit.

(c) Blanket authorization denying substitutions shall not be permitted. Each prescription or in-patient medication order shall state "Brand Medically Necessary" in the prescriber's own handwriting. For non-MAC drugs, each prescription order shall follow the requirements of 24:6E-1et seq.

(d) For claims with service dates on or after July 1, 1999, the pharmacist shall dispense the least expensive, therapeutically effective nutritional supplement or specialized infant formula, at the time of dispensing, unless the prescriber indicates in his or her own handwriting on each written prescription or follow-up written prescription to a telephone rendered prescription the phrase "Brand Medically Necessary."

(e) The dispenser must always report the actual labeler code and drug product code of the drug dispensed. The package size code reported may differ from the stock package size used to fill the prescription.

N.J. Admin. Code § 10:51-2.17

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