New Jersey Administrative Code

(a) For pharmacy claims with service dates on or after May 3, 1999, that exceed DUR Board standards, the PAAD program shall utilize the medical exception process (MEP) to allow the override of a claim denial, when medically necessary. 1. The MEP may be administered by a vendor on…

(a) A pharmacy, with a retail or institutional permit, may participate in the PAAD program as a provider of pharmaceutical services. (b) To be approved as a provider of pharmaceutical services, the pharmacy shall: 1. Operate under a valid retail or institutional permit issued by …

Reimbursement for legend drugs shall be limited to manufacturers who have entered into a PAAD rebate agreement, including an agreement to pay rebates on claims for which PAAD is a secondary payer, with the Department of Human Services through the Division of Medical Assistance an…

Notes N.J. Admin. Code § 10:167A-1.4 New Rule, R.2003 d.248, effective 6/16/2003. See: 34 N.J.R. 3456(a), 35 N.J.R. 2642(a). Former N.J.A.C. 8:83C-1.4, Program restrictions affecting payment for prescribed drugs, recodified to N.J.A.C. 8:83C-1.6. Reserved by 49 N.J.R. 446(a), eff…

(a) All participating pharmacies shall provide services within the scope of the permit issued by the Board of Pharmacy of the State of New Jersey. Prescriptions must be dispensed in compliance with all current existing Federal and State laws. (b) All drugs must be prescribed. 1. …

(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable laws. However, the prescriber's discretion is limited for certain drugs. Reimbursement may be denied if any of the following, or any of the requirements of this chapter…

(a) Subject to the requirements of the annual State appropriations act, this section provides a summary of the elements involved in the calculations of the payment of legend or certain non-legend drugs. The elements include the following: 1. Program restrictions affecting reimbur…

Notes N.J. Admin. Code § 10:167A-1.8 Amended by R.1995 d.104, effective 2/21/1995. See: 26 N.J.R. 4136(a), 27 N.J.R. 684(a). Amended by R.1997 d.252, effective 6/16/1997. See: 28 N.J.R. 2481(a), 28 N.J.R. 3221(a), 29 N.J.R. 2678(a). Amended by R.1998 d.464, effective 9/8/1998. Se…

(a) The dispensing fee for each prescription dispensed to recipients by providers having retail permits, and where PAAD is the primary payer is $ 3.73 to $ 3.99. Additional dispensing fees (add-ons) per prescription shall be given, when PAAD is the primary payer, to pharmacy prov…

(a) It is intended that the Senior Gold Prescription Discount Program shall extend assistance to certain persons whose level of income disqualifies them for benefits and medical assistance under the New Jersey Medical Assistance and Health Services Act and for prescription benefi…

These rules are promulgated under the authority of the Senior Gold Prescription Discount Act, P.L. 2001, c. 96. Notes N.J. Admin. Code § 10:167B-1.2

The following words and terms, when used in this chapter, shall have the following meanings, unless the context clearly indicates otherwise: "Annual income" means all income from whatever source derived, actually received or anticipated. "Anticipated income" means the amounts of …

(a) To be considered a special needs trust, the trust shall include the following provisions: 1. The trust shall specifically state that the trust is for the sole benefit of the trust beneficiary; 2. The trust shall specifically state that its purpose is to permit the use of trus…

The Department is the administrative unit of the State government which has control over the administration of Senior Gold. Under the terms of the Senior Gold Prescription Discount Act, this Department is responsible for the general policies governing administration of Senior Gol…

The Division of Aging Services is the administrative unit within the Department that processes applications, determines eligibility, answers inquiries, mails eligibility cards and performs other administrative functions for, or in conjunction with, the Department. Notes N.J. Admi…

The Senior Gold Prescription Discount Program in the Office of Support Services for the Aged within the Department, has the direct responsibility for the processing of eligibility applications from applicants. Notes N.J. Admin. Code § 10:167B-3.3

By statute, the Senior Gold Prescription Discount Program is limited to payment or reimbursement to pharmacies for the reasonable cost of prescription drugs for eligible persons which exceeds the co-payment. Notes N.J. Admin. Code § 10:167B-4.1

(a) In order to become an approved provider, a pharmacy must file an application and agreement of participation which must be approved by the Division of Medical Assistance and Health Services of the Department of Human Services. (b) No reimbursement will be made to an unlicensed…

(a) The Program shall provide a payment to a pharmacy that is participating in the Program for the reasonable cost of one or more prescription drugs purchased by an eligible person who presents an identification card issued by the program in an amount that exceeds the co-payment …

(a) Whenever any interchangeable drug product contained in N.J.A.C. 8:71 is available for the prescription written, the Program shall reimburse only for the reasonable cost of the interchangeable product less the Senior Gold co-payment unless the prescriber specifies that substit…

(a) No direct payment to beneficiaries will be made under the Senior Gold Program except as noted in (b) below. The beneficiary must pay the pharmacy a non-refundable Senior Gold co-pay per prescription drug. (b) In the event that a beneficiary receives his or her eligibility ide…

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 for the purpose of initiating such application: 1. Power of attorney; 2. A close relative by …

(a) The Senior Gold eligibility effective date for an initial Senior Gold applicant, who meets all the Senior Gold eligibility criteria, is the date when a valid and complete eligibility application is approved by the Program. (b) The Department shall conduct periodic reassessmen…

(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 Department has the responsibility for reviewing a statistically valid representative sample of Senior Gold cases to assure beneficiary eligibility. A quality control review of sample cases selected on a random basis includes: 1. Analysis of the beneficiary's case record, …

(a) The Program has responsibility in the application process to: 1. Explain the purposes and eligibility requirements of the Program and indicate the applicant's rights and responsibilities under its provisions; 2. Process applications and reapplications; 3. Issue eligibility ca…

(a) To be eligible for Senior Gold, 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 the…

(a) A Senior Gold eligibility card is effective for the dates indicated on the card. The Senior Gold beneficiary shall renew his or her eligibility in accordance with the provisions of N.J.A.C. 10:167B-6.6. (b) Renewal applications must be completed and returned to the Senior Gol…

(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 his or her authorized agent. (b) Disclosure o…

(a) When the Program determines that an applicant is ineligible for benefits, the applicant has the right to appeal the decision by submitting a written request for a fair hearing to the Senior Gold Prescription Discount Program, PO Box 724, Trenton, New Jersey 08625-0724, 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 a total annual income between $ 28,769 and $ 38,769 in 2021 to be eligible for Senior…

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

(a) "Resident" means a resident as defined in section 3 of P.L. 1975, c.194 (N.J.S.A. 30:4D-22) for purposes of eligibility 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 P…

(a) The Senior Gold Prescription Discount Act provides that an eligible person whose prescription drug costs are covered in part by any other program or plan of assistance or insurance may be required to receive reduced assistance under the Program. If an eligible person's prescr…

(a) The Senior Gold Eligibility application (Form SG-1) is the only acceptable form to be utilized in determining the applicant's initial eligibility for Senior Gold. These applications and brochures are available at the local Social Security Office, the County Office on Aging, t…

(a) Senior Gold applicants are not required to submit their Social Security Account Number (SSAN); however, failure to provide it will delay the processing of their application. Each applicant for Senior Gold benefits must include his or her SSAN on the application/reapplication …

The applicant for Senior Gold 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 or her knowledge. This certification must be dated, signed or marked by the applicant and spous…

(a) By signing or marking the certification and authorization statement on a Senior Gold eligibility 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…

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 or her death because of assistance paid, or to be paid, on his or her behalf under the Senior Gold Program, except for assistance incorrectly…

(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 in accordance with N.J.S.A. 30:4D-45.1. 1. The term "incorrect payment" includes, but is not limited to: i. Paymen…

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 § 10:167B-7.3

Any person violating any provision of the Senior Gold Prescription Discount 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 vi…

(a) It is intended that the Senior Gold Prescription Discount Program shall extend assistance to certain persons whose level of income disqualifies them for benefits and medical assistance under the New Jersey Medical Assistance and Health Services Act and for prescription benefi…

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 N.J.A.C. 8:71. The labeler code and drug product code of the actual product di…

(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. 10:167C-1.5, Basis of payment). (b) The usual and customary charge to the Program is defined as the amount a provi…

(a) All covered pharmaceutical services shall be provided within the scope of the Medicaid or Senior Gold programs, and billed to the fiscal agent on the claim form or other approved billing method (see N.J.A.C. 10:51, Appendix D, incorporated herein by reference, Fiscal Agent Bi…