New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 58 - NURSE MIDWIFERY SERVICES › Subchapter 2 - PROVISIONS FOR SPECIFIC SERVICES › Section 10:58-2.17 - Pharmaceutical services; drugs prescribed and administered by a CNM

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All covered pharmaceutical services provided under the New Jersey Medicaid/NJ FamilyCare programs shall be provided to Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries within the scope of N.J.A.C. 10:49, Administration chapter; N.J.A.C. 10:51, Pharmaceutical Services; and N.J.A.C. 10:58, Certified Nurse Midwifery Services.
(b) All drugs shall be prescribed drugs. (See definition of "prescribed drugs" in 10:58-1.3.)
(c) The New Jersey Medicaid/NJ FamilyCare programs shall reimburse Medicaid/NJ FamilyCare participating pharmacies for pharmaceutical services prescribed by the certified nurse midwife if all the requirements of the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs for pharmaceutical services are met.
(d) The following requirements shall be met for the following services:
Service
Requirement
Covered pharmaceutical services
10:51-1.11
Prior-authorized services
10:51-1.13
Quantity of medication dispensed
10:51-1.14
Dosage and directions
10:51-1.15
Telephone-rendered original prescription
10:51-1.16
Changes or additions to the original prescription
10:51-1.17
Prescription refill
10:51-1.18
Prescription Drug Price and Quality
Stabilization Act
10:51-1.19
Non-proprietary or generic dispensing
10:51-1.9
Drug Efficacy Study Implementation (DESI)
10:51-1.20
N.J.A.C. 10:51,
Appendix A
Drug Manufacturers' Rebate Agreement
10:51-1.21
(e) Diabetic testing materials, including blood glucose reagent strips, urine monitoring strips, tapes, tablets, and lancets, may also be reimbursed. Electronic blood glucose monitoring devices or other devices used in the monitoring of blood glucose levels are considered medical supplies and are covered services by the Medicaid/NJ FamilyCare-Plan A fee-for service programs if they meet all applicable requirements of the New Jersey Medicaid/NJ FamilyCare programs. These services may require prior authorization from the Medical Assistance Customer Center (MACC). (See Medical Supplier Services Chapter, N.J.A.C. 10:59.)
(f) The New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall reimburse the certified nurse midwife for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office or home, as follows:
1. Certified nurse midwife-administered medications shall be reimbursed directly to the certified nurse midwife under certain situations. (See N.J.A.C. 10:58-3 for a listing of HCPCS procedure codes, "J" codes and applicable 3rd level procedure codes.)
i. An office or home visit (when the criteria for an office or home visit is met) and the procedure code for the method of drug administration may be billed in conjunction with a "J" code. The HCPCS 90782, 90784, 90785 and 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration, respectively.
ii. The New Jersey Medicaid/NJ FamilyCare programs have assigned HCPCS procedure codes and maximum fee allowances at 10:58-3.4 and 3.5 for specific drugs. Reimbursement to the certified nurse midwife for these specific drugs shall be based on the Average Wholesale Price (AWP) of a single dose of an injectable or inhalation drug, or the CNM's acquisition cost, whichever is less.
iii. Unless otherwise indicated in N.J.A.C. 10:58-3, or (f)1iv through vii below, the Medicaid/NJ FamilyCare fee-for-service maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid/NJ FamilyCare fee-for-service maximum fee allowance shall be based on the cost per vial.
iv. When a certified nurse midwife office or home visit is made for the sole purpose of administering a drug, reimbursement shall be limited to the cost of the drug and its administration. In these situations, there is no reimbursement for a certified nurse midwife's office or home visit. If, in addition to the certified nurse midwife's administration of a drug, the criteria of an office or home visit are met, the cost of the drug and administration may, if medically indicated, be reimbursed in addition to the visit.
v. No reimbursement will be made for vitamins, liver or iron injections or combination thereof, except in laboratory-proven deficiency states requiring parenteral therapy.
vi. No reimbursement will be made for drugs or vaccines supplied free to the CNM, for placebos, or for any injections containing amphetamines or derivatives thereof.
vii. No reimbursement will be made for injection given as a preoperative medication or as a local anesthetic which is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.