N.J. Admin. Code § 10:51-1.26

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

Section 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.

N.J. Admin. Code § 10:51-1.26

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