N.J. Admin. Code § 10:51-1.26 - Prospective drug utilization review (PDUR) program
(a) The
Division of Medical Assistance and Health Services has established a
prospective drug utilization review (PDUR) program to assist pharmacy providers
with monitoring drug utilization by Medicaid and NJ FamilyCare fee-for-service
beneficiaries. As a component of the Medicaid or NJ FamilyCare point-of-sale
(POS) claims adjudication system, the State's fiscal agent will review drug
utilization based on claims submitted on-line and provide pharmacists with
responses in real time regarding utilization within PDUR standards recommended
by the New Jersey Drug Utilization Review (DUR) Board, and approved by the
Commissioner of the Department of Human Services (DHS), and the Commissioner of
the Department of Health (DOH). Similar responses related to EMC or paper
claims processed by the New Jersey Medicaid Management Information System
(NJMMIS) shall be received by pharmacies on the Remittance Advice statement.
1. PDUR standards recommended by the New
Jersey DUR Board and approved by the Commissioners of the DHS and (DOH) shall
be based on standards in official compendia and accepted medical literature as
included in those established by First Data Bank (FDB) as part of the FDB DUR
information system. The FDB standards are incorporated herein by reference and
may be obtained from First Data Bank, The Hearst Corp., 1111 Bayhill Dr., San
Bruno, CA 94066.
2. PDUR standards
recommended by the New Jersey Drug Utilization Review (DUR) Board and approved
by the Commissioners of DHS and (DOH) shall be applied to all pharmacy claims,
regardless of mode of claim submission.
(b) POS participating pharmacy providers
shall be required to meet the conditions described in
N.J.A.C.
10:51-1.25.
(c) In addition to POS responses related to
adjudication of Medicaid or NJ FamilyCare fee-for-service pharmacy claims
returned to the pharmacy, pharmacists shall be notified regarding drug
utilization inconsistent with adopted PDUR standards which may include, but not
be limited to:
1. Drug-drug
interactions;
2. Maximum/minimum
daily dosage;
3. Therapeutic
duplication;
4. Drug-age
conflicts;
5. Duration of
therapy;
6. Drug-pregnancy
precautions;
7. Drug-gender
conflicts;
8. Under-usage;
and
9. Weight-based.
(d) The PDUR program may apply
adopted standards based on a severity index recommended by the New Jersey DUR
Board to determine appropriate pharmacist intervention and/or claim disposition
(that is, payment or denial) of Medicaid and NJ FamilyCare fee-for-service
pharmacy claims.
(e) Based on the
severity of a potential PDUR conflict or interaction, pharmacists shall be
required to consult with the beneficiary and/or prescriber to resolve matters
indicated by PDUR messages returned by the POS system.
(f) The pharmacists intervention requirements
related to the PDUR program are in addition to beneficiary interactions related
to the "offer to consult" as described in
N.J.A.C.
13:39-7.14, Patient profile record
system.
Notes
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