N.J. Admin. Code § 11:24-5.7

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

Section 11:24-5.7 - Health care services for prescribed drugs

(a) HMOs which provide pharmacy services, prescription drugs or a prescription drug plan shall comply with the requirements set forth at N.J.S.A. 26:2J-4.7, as well as the requirements set forth at N.J.A.C. 11:24-18, in the event that the HMO imposes a formulary upon the pharmacy services, prescription drug coverage or prescription drug plan.

(b) In accordance with N.J.S.A. 26:2J-4.5, an HMO which provides health care services for prescribed drugs approved by the Federal Food and Drug Administration (FDA) shall also provide health care services for prescribed drugs which have not been approved by the FDA if it is recognized to be medically appropriate for the specific treatment for which the drug has been prescribed in one of the following established reference compendia:

1. The American Medical Association drug Evaluations;

2. The American Hospital Formulary Service Drug Information;

3. The United States Pharmacopeia Drug Information; or

4. A clinical study or review article in a major-peer reviewed professional journal.

(c) Notwithstanding the provisions of this section, coverage shall not be required for any experimental or investigational drug or any drug which the FDA has determined to be contraindicated for the specific treatment for which the drug has been prescribed. Health care services provided pursuant to this section shall be determined and provided to the same extent as other services under the enrollee plan for drugs prescribed for treatments which have been approved by the FDA.

(d) Any coverage of a drug required by this section shall also include medically necessary services associated with the administration of the drug.

N.J. Admin. Code § 11:24-5.7

Amended by R.2000 d.183, effective 5/1/2000.
See: 31 N.J.R. 953(a), 32 N.J.R. 1544(a).
In (a), inserted a reference to prescription drugs and prescription drug plans.
Amended by R.2002 d.265, effective 8/19/2002.
See: 34 N.J.R. 885(a), 34 N.J.R. 3014(a).
Rewrote (a).