N.J. Admin. Code § 10:51-1.11

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

Section 10:51-1.11 - Covered pharmaceutical services

(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.

(c) For beneficiaries in the Medically Needy component of the New Jersey Care ... Special Medicaid programs, pharmaceutical services are available to pregnant women, dependent children and aged, blind or disabled Medically Needy beneficiaries residing in nursing facilities. For information on how to identify a Medicaid beneficiary, see N.J.A.C. 10:49, Administration.

(d) Prescribed legend drugs commercially available in unit-dose packaging, dispensed as part of a unit-dose drug distribution system, and/or unit-of-use packaging and dispensed to beneficiaries residing in nursing facilities (NFs), assisted living residences (ALRs) and comprehensive personal care homes (CPCHs) shall be a covered service under the following circumstances:

1. For unit-dose drug distribution systems, drugs shall be delivered to the resident's living area in single unit packaging which meets the following criteria:

i. Each resident shall have his or her own medication tray labeled with the resident's name and location in the facility;

ii. Each medication shall be individually wrapped and labeled by the manufacturer with the generic or trade (brand) name and strength of the drug, lot number or reference code, expiration date, dose, and manufacturer's name, and shall be ready for administration to the resident;

iii. Cautionary instructions shall appear on the resident's record of medication, and the system shall include provisions for noting additional information, including, but not limited to, special times or routes of administration and storage conditions; and

iv. Delivery and exchange of resident medication trays shall occur promptly, and at least one exchange of resident medication trays shall occur every 24 hours, including weekends and holidays.

2. For unit-of-use packaging, drugs shall be delivered to the resident's living area either in single unit packaging, bingo or punch cards, blister or strip packs, or other system where each drug is physically separate. Individually labeled unit-dose medications may be combined in a "bingo or punch card" to create a unit-of-use drug distribution system.

(e) For beneficiaries covered under a managed care contract, atypical antipsychotics shall be reimbursed fee-for-service through the State's fiscal agent.

(f) On and after July 1, 2006, payments for erectile dysfunction drugs shall be limited to four treatments per month for male beneficiaries over the age of 18 who have a diagnosis of erectile dysfunction and who are not registered on New Jersey's Sex Offender Registry.

1. The face of the prescription shall contain the statement "Diagnosis of erectile dysfunction," written by the prescriber.

N.J. Admin. Code § 10:51-1.11

Amended by R.1995 d.358, effective 7/3/1995.
See: 27 N.J.R. 1104(a), 27 N.J.R. 2614(b).
In (b) added 3.
Amended by R.1998 d.488, effective 9/21/1998.
See: 30 N.J.R. 2169(b), 30 N.J.R. 3538(a).
In (b), inserted a new xi, recodified former xi through xv as xii through xvi, inserted a new xvii, recodified former xvi as xviii, inserted a new xix, and recodified former xvii through xxii as xx through xxv; and rewrote (c).
Amended by R.2003 d.131, effective 3/17/2003.
See: 34 N.J.R. 2897(a), 35 N.J.R. 1423(a).
Added (d).
Amended by R.2004 d.26, effective 1/20/2004.
See: 35 N.J.R. 3788(a), 36 N.J.R. 558(a).
In (b), added a new 2 and recodified former 2 and 3 as 3 and 4; added (e) and (f).
Amended by R.2007 d.109, effective 4/16/2007.
See: 38 N.J.R. 5304(a), 39 N.J.R. 1485(a).
Rewrote (f).