New Jersey Administrative Code

The Pharmaceutical Assistance to the Aged and Disabled is the program in the Department which has the direct responsibility for the processing of eligibility applications from applicants. Notes N.J. Admin. Code § 10:167-3.3

By statute, the Pharmaceutical Assistance to the Aged and Disabled Program is limited to payment or reimbursement to pharmacies for the reasonable cost of prescription drugs for eligible persons, which exceeds the PAAD co-pay and to Medicare Part D authorized prescription drug pl…

(a) Reimbursement for PAAD prescriptions shall be made only to pharmacies located in New Jersey except as indicated in (b)1 below and operating under a valid permit from the Board of Pharmacy of the State of New Jersey. In order to become an approved provider, such a pharmacy mus…

(a) Whenever PAAD is the primary payer and any interchangeable drug product is available for the prescription written, the PAAD Program shall reimburse for multisource generic drugs without prior authorization, but not for multisource brand name drugs without prior authorization.…

(a) No direct payment to beneficiaries shall be made under the PAAD Program, except as noted in (b) below. The beneficiary must pay the pharmacy a nonrefundable PAAD co-pay per prescription or per purchase of insulin, insulin syringes, insulin needles or syringes and needles for …

(a) The Department shall pay Medicare Part D premiums to the PDP on behalf of PAAD beneficiaries in accordance with the Fiscal Year 2016 Appropriations Act, P.L. 2015, c. 63, approved June 26, 2015, as amended and supplemented by subsequent State appropriations acts. 1. If the PD…

The application process includes all activity relating to a request for eligibility determination. It begins with the receipt by the Department of an eligibility application and continues in effect until there is an official disposition of the request by the Department. Notes N.J…

(a) In those instances where the applicant is incompetent or incapable of filing an eligibility application on his or her own behalf, the Department shall accept any one of the following listed in the order of priority, as an authorized agent for the purpose of initiating such ap…

(a) The PAAD eligibility effective date for an initial PAAD applicant, who meets all of the PAAD eligibility criteria, is the date when processing of a valid and complete eligibility application is completed by the PAAD program. (b) The PAAD program shall conduct periodic redeter…

(a) There may be exceptional cases where the processing of an eligibility application cannot be completed within a normal 30-day period. Where substantially reliable evidence either of eligibility or ineligibility is still lacking; the application shall be continued in pending st…

(a) The Commissioner shall establish operating policies within the Department to expedite the processing of applications and assure the maximum possible compliance with the standards set forth in this manual. (b) The Department has the responsibility for reviewing a statistically…

(a) Pursuant to statutory authority, the Department establishes procedures on the application process consistent with law and supervises the operation with the policy and procedures so established. (b) The Pharmaceutical Assistance to the Aged and Disabled Program has responsibil…

(a) There shall be only one application for those beneficiaries who apply for both PAAD and Lifeline. 1. A beneficiary may file one application for both programs on the same form. 2. If an applicant wishes to apply only for Lifeline, he or she shall use the PAAD eligibility appli…

(a) To be eligible for PAAD, the applicant shall be 65 years of age or older or shall be under 65 and over 18 years of age and receive Social Security Title II disability benefits. Individuals under age 65 who receive disability benefits on behalf of someone other than themselves…

(a) A PAAD eligibility card is effective for the dates indicated on the card. PAAD shall automatically renew each beneficiary's eligibility card annually unless PAAD determines, in its sole discretion, that a beneficiary must submit current information by completing a renewal app…

(a) All personally identifiable information regarding applicants or beneficiaries obtained or maintained under this program shall be confidential and shall not be released without the written consent of the applicant or beneficiary or their authorized agent. (b) Disclosure of inf…

(a) When PAAD determines that an application is ineligible for benefits, the applicant has the right to appeal the decision by submitting a written request for a fair hearing to Pharmaceutical Assistance to the Aged and Disabled, PO Box 715, Trenton, New Jersey 08625-0715, within…

(a) Any single permanent resident of New Jersey who is 65 years of age or over or who is under 65 and over 18 years of age and is receiving Social Security Title II disability benefits must have an annual income of less than $ 28,769 to be eligible for PAAD. (b) Any married perma…

A person shall not be required to be a citizen of the United States in order to be eligible for PAAD. Notes N.J. Admin. Code § 10:167-6.3

(a) The statute provides that "any . . . resident of this State . . . shall be eligible for PAAD. 'Resident' means one legally domiciled within the State for a period of 30 days immediately preceding the date of application for inclusion in the program. Mere seasonal or temporary…

(a) The State statute provides that any person shall be ineligible for PAAD if he/she is otherwise qualified for assistance under the Act of which the PAAD Act is a supplement (Chapter 413, Laws of 1968). This is interpreted to mean that a State resident 65 years of age or older …

(a) The eligibility application forms are available to applicants in central and local offices and other convenient locations throughout the State, on the Department's website at www.state.nj.us/humanservices/doas/home/ap2.html, and by writing to the New Jersey Department of Huma…

(a) Each applicant for PAAD benefits must include his or her Social Security Account Number (SSAN) on the application/reapplication form. The SSAN is a unique and verifiable number which is utilized to differentiate between persons with the same name. Married persons must also in…

The applicant for PAAD benefits must certify that all the answers to the questions and items on the application/renewal application form are true and accurate to the best of his/her knowledge. This certification must be dated, signed or marked by the applicant and spouse (if marr…

(a) By signing or marking the certification and authorization statement on an application or a renewal application form, an applicant or a reapplicant authorizes: 1. The Department to serve as the authorized representative of the applicant or reapplicant; 2. The Department to ver…

Pursuant to P.L. 1983, C. 371, no encumbrance or recovery of any kind shall be imposed or sought from the estate of a qualified applicant or an eligible person after his death because of assistance paid, or to be paid, on his behalf under the PAAD program, except for assistance i…

(a) As provided in N.J.S.A. 30:4D-1 et seq., the Department may take all necessary action to recover the cost of benefits incorrectly paid on behalf of a beneficiary.1. The term "incorrect payment" includes, but is not limited to: i. Payment made on behalf of a beneficiary whose …

Provisions for the application of liens shall be consistent with and conform to any provisions for liens as provided in N.J.S.A. 30:4D-1 et seq. Notes N.J. Admin. Code § 10:167-7.3

Any person violating any provision of the PAAD Act shall be subject to the applicable civil and criminal penalties contained in the "New Jersey Medical Assistance and Health Services Act" (N.J.S.A. 30:4D-1 et seq.). In addition, any eligible person who violates any provision of t…

This subchapter provides information about the provision of pharmaceutical services under the PAAD program, which shall extend assistance to certain persons whose level of income disqualifies them for medical assistance under the Medical Assistance and Health Services Act, but wh…

(a) Beneficiaries in the PAAD program are responsible for a part of the cost of drugs and devices covered by the PAAD program. At the point of sale, a PAAD beneficiary shall render to a pharmacy provider a fixed or adjustable copayment of an amount determined appropriate by the L…

(a) Compounded prescriptions may be reimbursed by the PAAD program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and are dispensed by approved providers. (b) Claims for compounded prescriptions shall be electronically subm…

When medication is prescribed by its non-proprietary or generic name, the pharmacist shall dispense the least expensive, therapeutically effective equivalent product available, preferably one listed in the list of interchangeable drug products. The labeler code, drug product code…

(a) The provider's usual and customary charge or advertised charge is an element considered in the calculation of the basis of payment for legend drugs (see N.J.A.C. 10:167A-1.7, Basis of payment). (b) The usual and customary charge to the PAAD program is defined as the amount a …

(a) All covered pharmaceutical services shall be provided within the scope of the Medicaid or PAAD programs, and billed to the fiscal agent using the NCPDP claim format available at http://www.njmmis.com/downloadDocuments/NJ_D-0_NCPDP_Payer_Sheet.pdf. (b) Covered pharmaceutical s…

(a) The following classes of prescription drugs or conditions are not covered under the PAAD program: 1. Prescriptions which are not for medically accepted indications as defined in Section 1927(k)(6) of the Social Security Act; 2. Drug products for which adequate and accurate in…

(a) Days supply limitations for an Initial Prescription Claim for PAAD beneficiaries shall be different from days supply limitations for a Refill Prescription Claim. 1. As used in this section, "Initial Prescription Claim" shall mean a PAAD claim for a drug not previously paid by…

(a) Dosage and directions for use shall be indicated on all prescriptions. Prescriptions written and dispensed with no specific directions, such as "prn," "as directed" or "ad lib," etc. are not eligible for reimbursement. Specific directions such as "1 tablet 4 times a day PRN" …

(a) Telephone, facsimile or electronically transmitted orders from prescribers for original prescriptions shall be permitted in accordance with all applicable Federal and State laws and regulations. (b) For purposes of reimbursement, telephone-rendered or faxed authorization to r…

Changes or additions to the original prescription, when approved by the prescriber, shall be clearly indicated (including date and time) and signed by the dispensing pharmacist. No changes (for example, dosage, quantity, number of refills, days supply, etc.) are permitted on the …

The following words and terms, when used in this chapter, shall have the following meanings unless the context clearly indicates otherwise: "Active pharmaceutical ingredient" means any substance or mixture of substances intended to be used in the manufacture of a drug product and…

(a) The provider shall submit an electronic claim in the proper EMC claim format to the fiscal agent for reimbursement of an allowable refill. An allowable refill shall comply with the following instructions in order to be reimbursed as such: 1. Refill instructions shall be indic…

(a) The Prescription Drug Price and Quality Stabilization Act, N.J.S.A. 24:6E-1 et seq., shall apply to the PAAD program. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." The prescriber shall initial one of…

(a) "Less than effective drugs" are subject to a Notice of Opportunity for Hearing (NOOH) by the Food and Drug Administration (FDA). 1. Reimbursement is not available for the purchase or administration of any drug product that meets all of the following conditions: i. The drug pr…

(a) "Bundled drug service" means a drug or service that is marketed or distributed by the manufacturer or distributor as a combined package which includes in the cost the drug product and ancillary services such as, but not limited to, case management services and laboratory test…

(a) An approved pharmacy provider shall enter into an agreement with a point-of-sale (POS) intermediary in accordance with the requirements of N.J.A.C. 10:167A-1.27 or directly provide a similar telecommunication network approved by DMAHS to submit claims to the fiscal agent for …

(a) An applicant shall be determined to be eligible for Pharmaceutical Assistance to the Aged and Disabled only if physically present in New Jersey at the time of application and utilization, in accordance with the provisions of N.J.A.C. 10:167. 1. Benefits shall not be payable f…