New Jersey Administrative Code

(a) Telephone 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 authorization to refill an original prescription with no refill remaining is …

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 or refills, days supply, etc.) are permitted on the …

(a) The provider shall submit a properly completed claim form or 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. Re…

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

(a) A pharmacy, with a retail or institutional permit, may participate in the Senior Gold 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 and/or institutional permit…

(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 may choose to: 1. Submit a properly completed hard copy pharmacy claim form approved by the New Jersey Division of Medical Assistance and Health Services (DMAHS); 2. Submit an electronic media claim (EMC) by modem, diskette or magnetic tape in an…

(a) An applicant shall be determined to be eligible for the Program only if physically present in New Jersey at the time of application and utilization, in accordance with the provisions of N.J.A.C. 10:167B. 1. Benefits shall not be payable for patients in nursing facilities, hos…

(a) Pharmacies shall verify that the beneficiary is a Senior Gold covered person. This is done by checking the beneficiary's Senior Gold identification card or by calling the Recipient Eligibility Verification System (REVS) at 1-800-676-6562. (b) The Program shall issue to all Se…

(a) Senior Gold pharmacy claims may be submitted through a point-of-sale (POS) system and adjudicated by the State's fiscal agent on-line and in real-time. The POS system is an alternative to other methods of claim submission, including magnetic tape, diskette and paper claims. T…

(a) The Drug Utilization Review (DUR) Board was established by law on June 30, 1998 (P.L. 1998, c. 41). A fully operational edit system began on December 1, 1999. The Division of Medical Assistance and Health Services of the Department of Human Services and the Department of Heal…

(a) For pharmacy claims that exceed DUR Board standards, the Senior Gold 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 behalf of the Department. 2. All phar…

Reimbursement for legend drugs shall be limited to manufacturers who have entered into a Senior Gold rebate agreement with the Department of Human Services through the Division of Medical Assistance and Health Services pursuant to N.J.A.C. 10:51-1.22. Notes N.J. Admin. Code § 10:…

(a) All participating pharmacies shall provide complete prescription services, including injectables and injectable anti-neoplastic agents, compounding, and prescription refill services, when allowable. Prescriptions must be dispensed in compliance with all current existing Feder…

(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 the requirements of the following rules are not met: 1. Covered …

(a) This section provides a summary of the elements involved in the calculation of the payment of legend or certain non-legend drugs. The elements include the following: 1. Program restrictions affecting reimbursement for the dispensing of drugs as listed in N.J.A.C. 10:167C-1.4;…

(a) Those pharmacy providers who have been in business for less than one calendar year shall have their prescription volume projected for the entire year, to determine the appropriate dispensing fee. (b) The Division of Medical Assistance (Medicaid) shall determine a provider's t…

(a) The dispensing fee for each prescription, dispensed by providers having retail permits to recipients other than those in nursing facilities, is $ 3.73. Additional dispensing fees (add-ons) per prescription shall be given to pharmacy providers who provide the following: 1. Twe…

(a) Beneficiaries in the Program are responsible for a part of the cost of drugs and devices covered by the Program. At the point of sale, a Senior Gold beneficiary shall render to a pharmacy provider a fixed co-payment of $ 15.00 plus 50 percent of the remaining cost of the drug…

(a) Compounded prescriptions may be reimbursed by the Program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved providers. 1. Acceptable pharmaceuti…

(a) The intent of the Lifeline Credit Program is to provide a minimum supply of gas and electricity for heating, lighting, cooling, cooking, and other essential household usages, which have been determined to be necessities of life, to those residential utility customers whose le…

The New Jersey State budget for fiscal year 2004 transferred the responsibility for funding the Lifeline Credit Program and the Tenants' Lifeline Assistance Programs' benefits to the Board of Public Utilities (BPU). Pursuant to a Memorandum of Understanding between the Department…

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 amount of inc…

(a) The Lifeline Credit shall consist of a single amount established by law, which will be applied, on a yearly basis, to the electric and/or gas utility bills of an eligible residential customer. Only one credit per year is allowed per household, regardless of the number of elig…

The Department of Human Services is the administrative unit of the State government designated to administer the Lifeline Programs. As provided in the "Lifeline Credit Program" and "Tenants' Lifeline Assistance Program" acts, this Department is authorized to promulgate policies, …

Lifeline Programs are administered by the Department, which has the direct responsibility for processing applications and determining eligibility for either program, reimbursing utility companies for credits issued, recovering benefits improperly issued and authorizing the paymen…

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

(a) Each electric and gas utility shall inform each eligible residential utility customer of the Lifeline Credit Program when so directed by the Commissioner. (b) Each electric and gas utility shall apply only one credit per utility account of an eligible residential utility cust…

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

The application process includes all activity relating to a request for an eligibility determination. The application process 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 t…

(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 recognize any of the following persons listed in order of priority, as an authorized agent for the purpose of initiating such …

(a) Pursuant to statutory authority, N.J.S.A. 48:2-29.31, the Department shall establish procedures on the application process consistent with law and supervise the operation with the policy and procedures so established. (b) The Department, through a Memorandum of Understanding …

(a) To be eligible for the Lifeline Credit Program, an individual shall be a resident and the residential utility customer each year or the spouse of a residential utility customer and satisfy one of the following criteria: 1. Be a Pharmaceutical Assistance to the Aged and Disabl…

The applicant must certify that all answers to the questions and items on the application form are true and accurate to the best of his or her knowledge. This certification shall be dated, signed or marked by the applicant and spouse, if married, and the preparer of the form, if …

(a) By signing or marking the certification and authorization statement on the application form, the applicant authorizes: 1. The Department to verify any information on the form by contacting the Social Security Administration, the Internal Revenue Service, the New Jersey Divisi…

A Lifeline Credit shall be applied to the account(s) of a residential utility customer and remain on the account until it is used or the account is terminated. See N.J.A.C. 10:167D-1.4. Notes N.J. Admin. Code § 10:167D-4.12 Amended by, 49 N.J.R. 3220(a), effective 9/18/2017.

(a) When the Department 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 Lifeline Credit Program, Department of Human Services, PO Box 722, Trenton, NJ 08625-0722,…

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

(a) Only residents of this State shall be eligible for the Lifeline Programs. (b) The applicant must be able to substantiate residence upon request by the Department, and is required to submit copies of two documents showing evidence of current residence at the time of applicatio…

(a) The applicant who is 65 years of age or older must be able to document his or her age upon request of the Department. The applicant must submit a copy of one of the following acceptable proofs of age: 1. Birth certificate; 2. Baptismal certificate; 3. Bris certificate; 4. Soc…

A person shall not be required to be a citizen of the United States in order to be eligible for the Lifeline Programs. Notes N.J. Admin. Code § 10:167D-4.5 Amended by, 49 N.J.R. 3220(a), effective 9/18/2017.

(a) The applicant who is between 18 and 65 years of age and is receiving Social Security Title II disability benefits must be able to document his or her Social Security disability determination upon request of the Department. The applicant must submit a copy of one of the follow…

(a) A residential utility customer shall submit documentation of his or her utility account(s) to the Department before a Lifeline Credit will be applied to his or her account. 1. A residential utility customer shall submit a copy of his or her most recent electric and/or gas bil…

(a) The Department shall mail a Lifeline Programs application to all Medical Assistance to the Aged, Medicaid Only beneficiaries and New Jersey Care Special Medicaid Program beneficiaries, except for those residing in nursing facilities, who are eligible each year. There shall be…

(a) Each applicant must include his or her Social Security Account Number (SSAN) on the application form. The SSAN, a unique and verifiable number, is utilized to differentiate between persons with the same name. Married persons must also indicate the SSAN of their spouse. (b) In…

(a) The Department shall take all necessary action to recover the Tenants Assistance payments incorrectly or illegally made or the Lifeline Credit incorrectly or illegally applied, on behalf of an electric and/or gas utility customer, from the residential utility customer and any…