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 (N.J.S.A. 24:6E-1 et seq.) (see N.J.A.C. 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 N.J.A.C. 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

N.J. Admin. Code § 10:51-1.4

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