N.J. Admin. Code § 10:51-1.4 - 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 law. However, the prescriber's discretion is limited
for certain drugs. Reimbursement may be denied if any of the following
requirements, or any of the requirements of this subchapter, are not met:
1. Prescription Drug Price and Quality
Stabilization Act (24:6E-1 et seq.) (see
10:51-1.20 );
i. Products listed in N.J.A.C. 8:71
(hereafter referred to as "the Formulary"), and all subsequent revisions,
distributed to all prescribers and pharmacists; and
ii. Non-proprietary or generic dispensing
(see 10:51-1.9 ).
(b) If a prescription is not
dispensed directly to the New Jersey Medicaid fee-for-service, NJ FamilyCare
fee-for-service, or Work First New Jersey/General Assistance (WFNJ/GA)
beneficiary for whom the prescription was written, and the claim charge exceeds
$ 150.00, the individual picking up the prescription shall present the Medicaid
Identification Card, the NJ FamilyCare Identification Card or the authorized
documentation confirming WFNJ/GA eligibility of the beneficiary. Without the
required proof of identity, the prescription shall only be dispensed in
accordance with (b)1 and 2 below:
1. If the
individual picking up the prescription cannot produce the beneficiary's
eligibility documentation, then the non-beneficiary shall produce a valid
driver's license as identification. Pharmacies shall record and maintain on
file the driver's license number of the non-beneficiary picking up the
prescription on the pharmacy signature log or a photocopy of the driver's
license presented by the non-beneficiary. Payments for Medicaid fee-for-service
or NJ FamilyCare fee-for-service covered pharmacy services not dispensed
directly to the beneficiary for whom there is no documentation or a photocopy
of the driver's license of the non-beneficiary picking up the prescription
shall be subject to full recovery by the State.
2. This subsection shall not apply to
prescription deliveries.
3. Such
documentation shall be retained by the pharmacy for at least five years from
the date the prescription was dispensed, and shall be available for review by
the Division or its authorized representatives upon request.
Notes
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