reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Subchapter 2 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) › Section 10:50-2.2 - HCPCS procedures codes and maximum fee schedule

Current through Register Vol. 56, No. 14, July 15, 2024
HCPCS Code
Mod.
Description
Maximum Fee Allowance
(a) AMBULANCE SERVICE
A0420
Waiting Time-Ambulance
						  Service--One
Way Trip Only
1/4 hour
2.50
1/2 hour
5.00
3/4 hour
7.50
1 hour
10.00
NOTE: Reimbursable only on one way trips and only
						  after 30 minutes have elapsed. It is reimbursable in 1/4 hour increments.
						  Maximum reimbursement for waiting time is $10.00 (1 hour).
A0422
Ambulance Service, Oxygen,
						  Administration and supplies, Life sustaining situation
12.00 per
						  occurrence
A0425
BLS Mileage (Per Mile)
6.04
NOTE: Ambulance Service, Per Mile, One Way and Round
						  Trip. Applicable when one-way mileage is 15 miles or less.
A0427
Air Ambulance Service, Advanced Life
						  Support (ALS) Level 1 (per unit)
387.14
A0429
Ambulance Services Basic Life Support
						  Emergency Transportation, No ALS (per unit)
326.02
A0433
Air Ambulance Service, Advance Life
						  Support Level 2 (per unit)
560.34
A0434
Specialty Care Transport (per unit)
647.33
A0436
Air Ambulance, Rotary
						  Wing
18.90
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 50 - TRANSPORTATION SERVICES MANUAL › Appendix - FISCAL AGENT BILLING SUPPLEMENT

Current through Register Vol. 56, No. 14, July 15, 2024
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as
				a part of this chapter/manual but is not reproduced in the New Jersey
				Administrative Code. When revisions are made to the Fiscal Agent Billing
				Supplement, a revised version will be placed on the fiscal agent's website:
www.njmmis.com
and will be filed with the
				Office of Administrative Law.
If you do not have internet access and would like to request a
				copy of the Fiscal Agent Billing Supplement, write to:
Gainwell Technologies
PO Box 4801
Trenton, New Jersey 08650-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Bldg. 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This chapter provides information about the provision of pharmaceutical services under the New Jersey Medicaid program and NJ FamilyCare program. It is divided into three subchapters.
1.N.J.A.C. 10:51-1 provides a pharmacy operating under a retail permit with the policies and procedures relevant to the provision of services to New Jersey Medicaid and NJ FamilyCare fee-for-service beneficiaries, excluding those residing in a nursing facility.
2.N.J.A.C. 10:51-2 pertains to a pharmacy providing pharmaceutical services to Medicaid beneficiaries in a nursing facility.
3.N.J.A.C. 10:51-3 explains the responsibility of a pharmacist acting as a consultant in a nursing facility or other public medical institution.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.2 - Participation of eligible providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A pharmacy with a retail or institutional permit may participate in the Medicaid or NJ FamilyCare program as a provider of pharmaceutical services and as a medical supplier providing medical supplies and durable medical equipment and as a provider of parenteral nutrition or intravenous therapy. The requirements for approval as a provider of these services are listed in (b) through (d) below.
(b) To be approved as a provider of pharmaceutical services, the pharmacy shall:
1. Operate under a valid retail and/or institutional permit issued by the Board of Pharmacy of the State of New Jersey or by the board of pharmacy of the state in which the pharmacy is located. A pharmacy operating under an out-of-State institutional permit and applying for approval as a retail pharmacy may not participate as an approved provider in the Medicaid or NJ FamilyCare program; and
2. File an application and sign an agreement with the Division of Medical Assistance and Health Services.
i. Upon sale or other change of ownership of an approved pharmacy, the agreement is automatically terminated. To execute a new agreement to participate in the Medicaid and NJ FamilyCare programs, the new owner(s) shall apply to the Division of Medical Assistance and Health Services, Department of Human Services, by contacting the Provider Enrollment Unit (see
N.J.A.C. 10:49
, Administration Chapter, Enroll ment Process) or the fiscal agent Provider Enrollment Unit (see Appendix D, Fiscal Agent Billing Supplement).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.3 - Conditions for participation as a provider of pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(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 Federal and State laws.
(b) All drugs must be prescribed.
1. "Prescribed drugs" mean simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are:
i. Prescribed by a practitioner licensed or authorized by the State of New Jersey, or the state in which he or she practices, to prescribe drugs and medicine within the scope of his or her license and practice;
ii. Dispensed by licensed pharmacists in accordance with regulations promulgated by the New Jersey State Board of Pharmacy, N.J.A.C. 13:39; and
iii. Dispensed by licensed pharmacists on the basis of a written prescription that is maintained in the pharmacist's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.4 - Program restrictions affecting payment for prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The choice of prescribed drugs shall be at the discretion of the prescriber within the limits of applicable law. However, the prescriber's discretion is limited for certain drugs. Reimbursement may be denied if any of the following requirements, or any of the requirements of this subchapter, are not met:
1. Prescription Drug Price and Quality Stabilization Act (24:6E-1 et seq.) (see 10:51-1.20 );
i. Products listed in N.J.A.C. 8:71 (hereafter referred to as "the Formulary"), and all subsequent revisions, distributed to all prescribers and pharmacists; and
ii. Non-proprietary or generic dispensing (see 10:51-1.9 ).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.5 - Basis of payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section provides a summary of the elements involved in the calculation of the payment of a legend or non-legend drug for both the Medicaid and NJ FamilyCare programs. The elements include the following:
1. Program restrictions affecting reimbursement for the dispensing of drugs as listed in 10:51-1.4;
2. Price information as supplied from a reference drug file contracted for this purpose by the fiscal agent and accepted by the Division as the primary source of pricing information for the New Jersey Medicaid Management Information System (NJMMIS). The drug price or ingredient cost shall not exceed the lower of the average wholesale price as supplied by the reference drug file contractor; the provider's usual and customary charge; or the drug's maximum allowable cost, if applicable (see (b) below);
i. The NJMMIS reference drug file is updated periodically by the fiscal agent based upon data supplied by First Data Bank (FDB). The update process provides the fiscal agent with current data to include changes in product description. Providers are made aware of therapeutic indications for various classes of drugs by product literature distributed by drug manufacturers and by various trade publications. Based on market information, providers can determine whether a product's therapeutic classification meet the criteria specified in 10:51-1.11 (Covered Pharmaceutical Services).
3. Federal regulations (42 CFR Part 447, Subpart I) that set the aggregate upper limits on payment for certain covered drugs in the Medicaid and NJ FamilyCare-Plan A pharmaceutical program. The Division applies the limits to NJ FamilyCare-Plans B and C. The Division refers to these upper limits as the "maximum allowable cost" (see (b) below); and
4. The provider's usual and customary charge for legend or non-legend drugs (see (c) below), contraceptive diaphragms and legend or non-legend devices.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.6 - Discounts

Current through Register Vol. 56, No. 14, July 15, 2024
For claims with service dates on or after July 15, 1996, the discount shall be 10 percent for each eligible prescription claim not covered by the Maximum allowable cost price.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.7 - Prescription dispensing fee

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The dispensing fee for legend drugs, dispensed by providers having retail permits to beneficiaries other than those in long-term care facilities, including State-operated Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), nursing facilities, and State- and county-operated long-term psychiatric hospitals, is $ 3.73. Additional dispensing fees (add-ons) per prescription shall be given to pharmacy providers who provide the following:
1. Twenty-Four Hour Emergency Service: $ 0.11. The provider shall have a 24-hour per day, 365-days-per-year prescription service available and shall have provided Medicaid or NJ FamilyCare beneficiaries opportunities to utilize this service.
2. Patient Consultation: $ 0.08. In addition to routinely monitoring beneficiary profiles for drug interactions, contraindications, allergies, etc., the provider shall, where appropriate, discuss the course of drug therapy with the beneficiary. This discussion must include emphasis on compliance with the prescriber's orders; proper drug utilization; cautions about possible side effects; foods to avoid; proper drug storage conditions; and any other information that will prove beneficial to the beneficiary while on drug therapy.
3. Impact Area Location: $ 0.15. The provider shall have a combined Medicaid/NJ FamilyCare, and Pharmaceutical Assistance to the Aged/Disabled (PAAD) prescription volume equal to or greater than 50 percent of the provider's total prescription volume.
i. The nursing facility prescription volume shall be included for the determination of total prescription volume in determining entitlement to the impact allowance.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.8 - Compounded prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Compounded prescriptions may be reimbursed by the Medicaid and NJ FamilyCare programs. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved pharmacy providers.
1. Acceptable pharmaceutical excipients which do not contribute therapeutically to a compound, include, but are not limited to hydrophilic ointment, petrolatum, aquaphor, eucerin cream, phenol, menthol, resorcinol, caffeine, talc, simple syrup, aromatic elixir, distilled water, and glycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.9 - Non-proprietary or generic dispensing

Current through Register Vol. 56, No. 14, July 15, 2024
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 dispensed must be reported on the claim form. The package size code reported may differ from the stock package size used to fill the prescription.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.10 - Provider's usual and customary charge or advertised charge

Current through Register Vol. 56, No. 14, July 15, 2024
(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 10:51-1.5, Basis of payment).
(b) The usual and customary charge to the Medicaid or NJ FamilyCare program is defined as the amount a provider charges the general public for a prescription for the same drug product (same NDC number) in the same quantity as the prescription being dispensed to a Medicaid or NJ FamilyCare beneficiary. "Usual and customary charge" means the actual charge made to the majority (51 percent) of the total patient population served by the individual pharmacy.
1. The provider shall not charge the programs more than would be charged to a cash customer when the general public, including private third party plans, accounts for more than 50 percent of a provider's total prescription volume.
i. In the event Medicaid, NJ FamilyCare and/or PAAD represent more than 50 percent of a provider's total prescription volume, then, for reimbursement purposes, the provider's usual and customary charge may be considered the amount the programs would reimburse for the same services.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.11 - Covered pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered pharmaceutical services shall be provided within the scope of the N.J.A.C. 10:49, Administration, and this chapter, and billed to the fiscal agent on the claim form or other approved billing method (see Appendix, Fiscal Agent Billing Supplement).
(b) Covered pharmaceutical services include:
1. Prescribed legend drugs (for their medically accepted indication) as defined in Section 1927(k)(6) of the Social Security Act. "Legend drugs" mean those drugs whose labels include the legend statement "Caution: Federal Law Prohibits Dispensing Without a Prescription."
2. In order for a brand name non-legend drug to be covered, the prescriber must document "Brand Medically Necessary" on the prescription. Otherwise, only the generic non-legend product is covered.
3. Non-legend drugs, as follows, for which Federal Financial Participation (FFP) is available:
i. Contraceptive devices and contraceptive supplies (such as diaphragms, jellies, foams and condoms);
ii. Over-the-counter, family planning supplies (such as pregnancy test kits);
iii. Pharmaceutical inhalation devices;
iv. Diabetic testing materials;
v. Insulin needles and/or syringes;
vi. Insulin; and
vii. Antacids.
4. In addition, coverage of non-legend drugs for beneficiaries under the age of 21 shall also include:
i. Analgesics, Salicylates;
ii. Analgesics/Antipyretics, Non-salicylate;
iii. Antidiarrheals;
iv. Anti-Emetics;
v. Antiflatulents;
vi. Antihistamines;
vii. Antipruritics;
viii. Antitussives, non-narcotic;
ix. Cathartics;
x. Cough and cold preparations;
xi. Decongestants
xii. Emetics;
xiii. Expectorants;
xiv. Hematinics;
xv. Iron replacement supplements;
xvi. Laxatives;
xvii. Lice treatment products;
xviii. Multiple vitamin preparations;
xix. Oral anti-inflammatory agents;
xx. Pediatric vitamin preparations;
xxi. Vitamins A, B, C, D, E, K, B1, B2, B6, B12 preparations;
xxii. Polymixin and derivatives;
xxiii. Topical preparations, antibacterial;
xxiv. Topical antibiotics; and
xxv. Topical anti-inflammatory preparations.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.12 - Personal contribution to care requirements for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D

Current through Register Vol. 56, No. 14, July 15, 2024
(a) General policies regarding the collection of personal contribution to care for NJ FamilyCare-Plan C and copayments for NJ FamilyCare-Plan D are set forth at N.J.A.C. 10:49-9.
(b) Personal contribution to care for NJ FamilyCare-Plan C services are $ 1.00 per dispensing for generics and $ 5.00 per dispensing for brand name drugs. Included in drugs are insulin, needles and syringes.
(c) Pharmacies are required to collect the personal contribution to care for the above-mentioned NJ FamilyCare-Plan C services if the NJ FamilyCare Identification Card indicates that a personal contribution to care is required and the beneficiary does not have a NJ FamilyCare form which indicates that the beneficiary has reached their cost share limit and no further personal contributions to care are required, until further notice. Personal contribution to care charges cannot be waived.
(d) The copayment for prescription drugs under NJ FamilyCare-Plan D shall be $ 5.00 per prescription:
1. If greater than a 34-day supply of a prescription drug is dispensed, a $ 10.00 copayment shall apply.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.14 - Services requiring prior authorization

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The provider shall obtain prior authorization, when required by this chapter, by phone or in writing, from the professional staff of the Division's prior authorization agent for pharmacy services. The pharmacy prior authorization agent is available at a toll-free telephone number 24 hours a day, seven days a week. When a form is required by this chapter, the appropriate form that must be used to request prior authorization is indicated in the Fiscal Agent Billing Supplement. Information on the form is transmitted, on-line, from the pharmacy prior authorization agent to the fiscal agent who, in turn, confirms the status of the authorization request by mail and provides the specific prior authorization number.
1. In an administrative emergency (see 10:49-6.1(b)3  ) when the pharmacy prior authorization agent is unavailable, the provider may dispense a 72 hour supply of the prescribed drug.
i. If the drug is to be continued beyond 72 hours, and the pharmacy prior authorization agent is unavailable, the provider may dispense a total of a five day's supply. If the drug is to be continued either beyond the 72 hours or five days period, the provider shall hold the claim and obtain prior authorization for the balance of the prescription when the pharmacy prior authorization agent is available during normal business hours.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.15 - Quantity of medication

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The quantity of medication prescribed shall provide a sufficient amount of medication necessary for the anticipated duration of the illness or, if required, an amount sufficient to provide medication during intervals between prescriber visits. The amount of medication dispensed shall not exceed a 34-day supply for initial prescriptions and a 34-day supply or 100 unit doses, whichever is greater, for refill prescriptions.
(b) Any medication continuously prescribed regardless of the frequency of administration, for a period of 14 days or more shall be considered a maintenance medication.
(c) The pharmacist shall dispense the full quantity of medication prescribed within the limitations described in (a) above.
(d) Prescriptions shall not be split or reduced in quantity, unless the quantity prescribed exceeds Program limits, in which case the quantity shall be reduced to Program limits described in (a) above.
1. Exception: When the full quantity prescribed (within Program limits) is not available when a prescription is ready to be dispensed, the pharmacist shall retain the claim form or submit an EMC claim after the balance of the medication is dispensed. The pharmacist may dispense the quantity available and shall notify the beneficiary accordingly.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.16 - Dosage and directions

Current through Register Vol. 56, No. 14, July 15, 2024
(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" are required.
1. Exceptions:
i. Topical preparations including ophthalmic and otic drops and ointments;
ii. Aerosol inhalers; and
iii. Nitroglycerin.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.17 - Telephone-rendered original prescriptions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Telephone orders from prescribers for original prescriptions shall be permitted in accordance with all applicable Federal and State laws, rules and regulations.
(b) For purposes of reimbursement, telephone authorization to refill an original prescription with no refill remaining is considered a new order and requires a new written prescription with a new prescription number. Stamping or writing a new number on the original prescription order does not constitute a new prescription under the Medicaid or NJ FamilyCare programs.
(c) When a prescriber chooses not to allow product interchange on a telephone order, the statement "Substitution not permitted by prescriber-telephone Rx" plus the pharmacist's full signature next to or below the statement, shall appear on the prescription order. A rubber stamp bearing the statement is acceptable.
(d) When a prescriber chooses to certify "Brand Medically Necessary" on a telephoned prescription for a product included on the Federal MAC list, a written signed prescription order containing the certification, shall be sent to the pharmacist within seven days of the date of the telephone order. The written prescription shall be retained by the pharmacist as the original prescription. Failure to comply will result in the payment for that prescription being reduced to the MAC reimbursement level.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.18 - Changes or additions to the original prescription

Current through Register Vol. 56, No. 14, July 15, 2024
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 original prescription order after the claim is submitted for payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.19 - Prescription refill

Current through Register Vol. 56, No. 14, July 15, 2024
(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. Refill instructions must be indicated in writing by the prescriber on the original prescription or verbally when telephoning the original prescription to the pharmacist. Verbal instructions shall be reduced to writing by the pharmacist, in accordance with 45:14-14.
2. When the prescriber indicates a prescription refill(s) on an original or telephone prescription for drugs, the number of refills shall be limited to a maximum of five refills within a six-month period.
3. Refill instructions indicating "refill prn" or indicating more than five refills, shall be subject to the limits imposed in (a)2 above, and shall be reimbursed up to these limits only.
4. A telephone authorized refill for a prescription with no refill remaining must be assigned a new prescription number.
5. Prescription refills shall not be dispensed until a reasonable quantity (approximately 75 percent) of the medication originally dispensed or refilled could have been consumed in accordance with the prescriber's written directions for use.
i. Exception: When a prescription is lost or destroyed, requiring a replacement prescription to be dispensed before the original prescription could have been consumed in accordance with the prescriber's written directions for use, an original pharmacy claim with written justification shall be submitted to the fiscal agent for payment consideration.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.20 - Prescription Drug Price and Quality Stabilization Act

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Prescription Drug Price and Quality Stabilization Act, 24:6E-1 et seq., shall apply to the New Jersey Medicaid and NJ FamilyCare programs. This law requires that every prescription blank contain the statements "Substitution Permissible" and "Do Not Substitute." The prescriber shall initial one of the statements in addition to signing the prescription blank.
1. When the prescriber does not initial "Substitution Permissible" or the "Do Not Substitute" statement on a prescription for a drug product listed in the DURC Formulary, the pharmacist shall substitute from the list of interchangeable products and bill Medicaid or NJ FamilyCare accordingly.
2. When the prescriber initials "Substitution Permissible," the pharmacist shall dispense and bill Medicaid or NJ FamilyCare for one of the less expensive products listed in the DURC Formulary as interchangeable with the brand name prescribed. The Medicaid or NJ FamilyCare beneficiary must accept the interchangeable product unless the beneficiary is willing to pay the pharmacy's full, usual and customary price. If that occurs, the pharmacist shall so note on the prescription blank and no claim shall be submitted to Medicaid or NJ FamilyCare.
3. For non-MAC drugs (see 10:51-1.5 ) when the prescriber initials "Do Not Substitute," the pharmacist shall indicate the prescriber's preference by indicating "Medical Certification" on the claim form or the similar field in the EMC claim format and shall dispense and bill Medicaid or NJ FamilyCare for the prescribed product. Reimbursement will be the estimated acquisition cost (EAC) (see 10:51-1.5 ) plus applicable dispensing fee or the usual and customary charge, whichever is less for that product (see Appendix D, Fiscal Agent Billing Supplement for instructions about the claim form and Appendix E regarding the proper EMC claim format.)
4. When the prescriber orders by the generic name, N.J.A.C. 8:71 (see 10:51-1.4 ) does not apply. The pharmacist shall dispense the least expensive, therapeutically effective product available to him or her at the time of dispensing. The product need not necessarily be from the list of interchangeable products.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.21 - Drug Efficacy Study Implementation (DESI)

Current through Register Vol. 56, No. 14, July 15, 2024
(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 product was approved by the Food and Drug Administration (FDA) before October 10, 1962;
ii. The drug product is available only through prescription;
iii. The drug product is the subject of a NOOH issued under Section 505(e) of the Federal Food, Drug, and Cosmetic Act and published in the Federal Register on a proposed order of FDA to withdraw its approval for the drug product because it has determined that the product is less than effective for all its labeled indications; and
iv. The drug product is at present the subject of an efficacy review study performed by FDA (see 21 CFR 310.6 including all subsequent amendments and supplements). The FDA efficacy review potentially can determine justification for a drug product's medical need. If a drug product fails this review, the product is classified as a DESI drug.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.22 - Drug manufacturers' rebate agreement

Current through Register Vol. 56, No. 14, July 15, 2024
(a) In order for legend drug products to be reimbursed by the New Jersey Medicaid or NJ FamilyCare program, manufacturers must have in effect a rebate agreement pursuant to Section 1927 et seq. of the Social Security Act ( 42 U.S.C. §
										1396R-8(i) ).
(b) Price information is supplied from a reference drug file subcontracted for this purpose by the fiscal agent and accepted by the Division as the primary source of pricing information for the New Jersey Medicaid Management Information System (NJMMIS). The calculated price shall not exceed the lower of the average wholesale price (AWP) or the Federal Fund Participation Upper Limit (FFPUL) as supplied by the reference drug file contractor.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.23 - Bundled drug service

Current through Register Vol. 56, No. 14, July 15, 2024
(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 testing.
(b) Bundled drug service shall not be eligible for reimbursement by the Medicaid or NJ FamilyCare program.
1. This provision may be waived at the discretion of the Commissioner if the Commissioner determines that a bundled drug service is less than or equal to the total cost of the unbundled components if reimbursed separately; or
2. The Commissioner may waive the provisions for reasons of medical necessity for a bundled drug or in accordance with terms approved by the Department as follows:
i. Those instances where discontinuation, withdrawal, or elimination of the use of the bundled drug by someone who has been receiving a bundled drug would result in the deprivation of the lifesaving or life prolonging benefits of the drug or would cause potential harm or serious exacerbation of the illness being treated; or
ii. Those instances where use of the bundled drug has shown marked improvement in the beneficiary's clinical status reflected in alleviation of symptoms, and elevation of level of function and independence.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.24 - Claim submission

Current through Register Vol. 56, No. 14, July 15, 2024
(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 approved electronic format which complies with the National Council Prescription Drug Program (NCPDP) standards Version 5.1 and Version 1.1, as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.
i. In order for a pharmacy provider to be eligible to submit an EMC claim to the Medicaid or NJ FamilyCare programs, a pharmacy provider or vendor of EMC services shall complete the "New Jersey Medicaid Provider Electronic Billing Agreement."
ii. The completed agreement shall be submitted to the fiscal agent and approved by the Division of Medical Assistance and Health Services.
iii. The pharmacy provider or vendor or EMC services shall submit electronic media claims under an approved submitter identification number and comply with EMC requirements contained in the EMC Manual, Appendix E, incorporated herein by reference.
iv. For the purposes of this subchapter, all electronically submitted claims, including POS claims, shall commonly be referred to as EMC claims; or
3. Enter into an agreement with a point-of-sale (POS) intermediary or directly provide a similar telecommunication network approved by DMAHS to submit claims to the fiscal agent for adjudication. POS claims require an electronic format approved by the Division which complies with the National Council Prescription Drug Program standards, Version 5.1 and Version 1.1, as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.25 - Point-of-sale (POS) claims adjudication system

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Medicaid or NJ FamilyCare fee-for-service pharmacy claims may be submitted through a 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. The pharmacist would be required to enter pharmacy claim detail data into a computer or POS device and transmit this data to the fiscal agent over a dedicated telephone line. Regardless of the method of claim submission, all claims will go through all New Jersey Medicaid Management Information System (NJMMIS) claims processing edits and the claims will be processed to determine their payment disposition (for example, paid or denied).
1. Pharmacy services provided to nursing facility and residential care residents utilizing 24 hour unit-dose or modified unit-dose drug delivery systems are precluded from the POS system.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.26 - Prospective drug utilization review (PDUR) program

Current through Register Vol. 56, No. 14, July 15, 2024
(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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 1 - PHARMACEUTICAL SERVICES › Section 10:51-1.27 - Medical exception process (MEP)

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For pharmacy claims with service dates on or after September 1, 1999, which exceed prospective drug utilization review (PDUR) standards recommended by the New Jersey DUR Board and approved by the Commissioner of the Department of Human Services (DHS) and the Commissioner of the Department of Health (DOH), the Division of Medical Assistance and Health Services has established a medical exception process (MEP) for Medicaid and NJ FamilyCare fee-for-service pharmaceutical services.
(b) The medical exception process shall be administered by a contractor, referred to as the MEP contractor, under contract with the Department of Human Services (DHS).
(c) The medical exception process shall apply to all pharmacy claims, regardless of claim media, unless exempted by the New Jersey DUR Board and the Commissioners of DHS and DOH in accordance with the rules of those Departments.
(d) The medical exception process is as follows:
1. Pharmacy providers shall be notified when submitting a claim that a prescription is limited to a maximum 30-day supply.
2. The pharmacy shall be responsible to contact the MEP contractor to decide if a medical exception is needed. If an exception is needed, the pharmacist may dispense medication for up to a 30-day calendar period. During this period, the MEP contractor shall issue a Prescriber Notification Letter which may include, but is not limited to, requesting from the prescriber the reason for the medical exception, diagnosis, expected duration of therapy, and the expiration date for the medical exception.
3. Following review and approval, if appropriate, of a prescriber's written justification, the MEP contractor shall override existing PDUR edits through the issuance of a prior authorization number.
4. The MEP contractor shall notify the pharmacy and prescriber of the results of the review by the close of the 30-day calendar period, and shall include, at a minimum, the beneficiary's name, mailing address, HSP number, the reviewer, service description, service date, and prior authorization number, if approved, the length of the approval and the appeals process if the pharmacist does not agree with the results of the review.
5. Pharmacies may request a fair hearing to appeal decisions rendered by the MEP contractor concerning denied claims (see N.J.A.C. 10:49-10, Notices, Appeals and Fair Hearings.)
6. Claims subject to the medical exception process which have exhausted the 30-day allowance period and for which prior authorization has not been issued by the MEP contractor shall be denied payment by the Medicaid/NJ FamilyCare programs.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.1 - Introduction

Current through Register Vol. 56, No. 14, July 15, 2024
This subchapter provides information about the provision of reimbursable pharmaceutical services provided to Medicaid or NJ FamilyCare fee-for-service beneficiaries in Medicaid approved nursing facilities.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.2 - Participation of eligible providers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A pharmacy with a retail or institutional permit may participate in the Medicaid and NJ FamilyCare programs as a provider of pharmaceutical services and as a provider of parenteral nutrition or intravenous therapy.
(b) To be approved as a provider of pharmaceutical services, the pharmacy shall:
1. Operate under a valid retail and/or institutional permit issued by the Board of Pharmacy of the State of New Jersey or by the board of pharmacy of the state in which the pharmacy is located. A pharmacy operating under an out-of-State institutional permit may not participate as an approved provider in the New Jersey Medicaid or NJ FamilyCare program; and
2. File an application and sign an agreement with the Division of Medical Assistance and Health Services.
i. Upon sale or other change of ownership of an approved pharmacy, the agreement is automatically terminated. To execute a new agreement to participate in the Medicaid and NJ FamilyCare programs, the new owner(s) shall apply to the Division of Medical Assistance and Health Services, Department of Human Services, by contacting the Provider Enrollment Unit. (See
N.J.A.C. 10:49
, Administration Chapter, Enrollment Process) or the fiscal agent Provider Enrollment Unit. (See Appendix D, Fiscal Agent Billing Supplement.)
3. To enroll as a Medicaid and NJ FamilyCare provider of pharmaceutical services, a pharmacy shall contact the fiscal agent Provider Enrollment Unit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.3 - Conditions for participation as a provider of pharmaceutical services

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All participating pharmacies shall provide complete prescription services, including injectables and injectable anti-neoplastic agents and compounding services, when allowable. Prescriptions and in-patient medication orders must be dispensed in compliance with all current existing Federal and State laws.
(b) All drugs must be prescribed.
1. "Prescribed drugs" mean simple or compound substances or mixtures of substances prescribed for the cure, mitigation, or prevention of disease, or for health maintenance that are:
i. Prescribed by a practitioner licensed or authorized by the State of New Jersey, or the state in which he or she practices, to prescribe drugs and medicine within the scope of his or her license and practice;
ii. Dispensed by licensed pharmacists in accordance with regulations promulgated by the New Jersey State Board of Pharmacy, N.J.A.C. 13:39; and
iii. Dispensed by licensed pharmacists on the basis of a written prescription and/or in-patient medication order that is recorded and maintained in the pharmacist's records.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.4 - Program restrictions affecting payment of prescribed drugs

Current through Register Vol. 56, No. 14, July 15, 2024
(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 requirements, or any of the requirements of the rules of this subchapter, are not met:
1. Prescription Drug Price and Quality Stabilization Act (24:6E-1 et seq.) (see 10:51-2.17 );
i. Products listed in N.J.A.C. 8:71 (hereafter referred to as "the Formulary"), and all subsequent revisions, distributed to all prescribers and pharmacists; and
ii. Non-proprietary or generic dispensing (see 10:51-2.9 );
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.5 - Basis of payment

Current through Register Vol. 56, No. 14, July 15, 2024
(a) This section provides a summary of the elements involved in the calculation of the payment of a legend drug. The elements include the following:
1. Program restrictions affecting reimbursement for the dispensing of drugs as listed in 10:51-2.4;
2. Price information as supplied from a reference drug file subcontracted for this purpose by the fiscal agent and accepted by the Division as the primary source of pricing information for the New Jersey Medicaid Management Information System (NJMMIS). The drug price or ingredient cost shall not exceed the lower of the average wholesale price as supplied by the reference drug file contractor; the provider's usual and customary charge; or the drug's Maximum Allowable Cost, if applicable (see (b) below);
i. The NJMMIS reference drug file is updated periodically by the fiscal agent based upon data supplied by First Data Bank (FDB). The update process provides the fiscal agent with current data to include changes in product description. Providers are made aware of therapeutic indications for various classes of drugs by product literature distributed by drug manufacturers and by various trade publications. Based on market information, providers can determine whether a product's therapeutic classification meet the criteria specified in 10:51-2.10 (Covered pharmaceutical services).
3. Federal regulations (42 CFR Part 447, Subpart I) that set the aggregate upper limits on payment for certain covered drugs in the pharmaceutical program. The Division refers to these upper limits as the "maximum allowable cost" (see (b) below); and
4. The provider's usual and customary charge for legend drugs (see (c) below), contraceptive diaphragms and legend devices.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 51 - PHARMACEUTICAL SERVICES MANUAL › Subchapter 2 - PHARMACEUTICAL SERVICES TO MEDICAID OR NJ FAMILYCARE FEE-FOR-SERVICES BENEFICIARIES IN A NURSING FACILITY › Section 10:51-2.6 - Discounts

Current through Register Vol. 56, No. 14, July 15, 2024
For claims with service dates on or after July 15, 1996, the discount shall be 10 percent for each eligible prescription claim not covered by the Maximum allowable cost price.