N.J. Admin. Code § 10:51-2.11

Current through Register Vol. 56, No. 21, November 4, 2024

Section 10:51-2.11 - Non-covered pharmaceutical services

(a) The following classes of prescription drugs or conditions shall not be covered under the New Jersey Medicaid or NJ FamilyCare program:

1. Prescriptions which are not for medically accepted indications as defined in Section 1927(k)(6) of the Social Security Act;

2. Antiobesics and anorexiants when used in treatment of obesity;

3. Drug products for which adequate and accurate information is not readily available, such as, but not limited to, product literature, package inserts and price catalogues;

4. Experimental drugs;

i. Exception: Drugs available only for treatment through an Investigational New Drug (IND) application may be prior authorized;

5. Medication furnished by a prescriber or an employee of a prescriber;

6. Medication prescribed for hospital inpatients;

7. Non-legend drugs;

8. Prescriptions and in-patient medication orders written and/or dispensed with nonspecific directions;

9. Food supplements, milk modifiers, infant formulas, therapeutic diets, special liquid or powdered diets used in the treatment of obesity;

10. Methadone in any form (tablets, capsules, liquid, injectables, or powder) when used for drug detoxification or addiction maintenance;

11. Drug products for which final orders have been published by the Food and Drug Administration, withdrawing the approval of their new drug application (NDA);

12. Drugs or drug products not approved by the Food and Drug Administration, when such approval is required by Federal law and/or regulation;

13. Radiopaque contrast materials (for example, Telepaque);

14. Drug Efficacy Study Implementation (DESI) drugs and identical, similar and related drugs (see 10:51-2.18 );

15. Drugs not covered by rebate agreements as defined in Section 4401 of OBRA '90 and Section 1927(a) of the Social Security Act (see 10:51-1.22 );

16. Erectile dysfunction drugs for individuals who are registered on New Jersey's Sex Offender Registry;

17. Any bundled drug service (see 10:51-2.20 ); and

18. Preventive vaccines, biologicals, and therapeutic drugs distributed to hospital clinics and/or community health centers by the New Jersey Department of Health.

(b) Otherwise reimbursable products shall be excluded from payment, under the following condition(s):

1. Products whose costs are found to be in excess of defined costs outlined in 10:51-2.5, basis of payment;

2. Drug products in dosage forms whose labeling, prescription or promotional material indicate the primary use is cosmetic in nature; for example, hair restoration;

3. Drug products available in unit-dose packaging and dispensed to residents in a boarding home or residential care setting or other community type setting. Other community type setting shall not include certain assisted living settings, including assisted living residences (ALRs), comprehensive personal care homes (CPCHs), and alternative family care (AFC) homes licensed by the Department of Health.

i. Drug products commercially available only as a unit-dose packaged product are covered when not otherwise marketed as a chemically equivalent product. The potency of equivalent products may or may not equal the potency of the unit-dose packaged product;

4. Drug products denied payment based on point-of-sale (POS) and prospective drug utilization review (PDUR) standards adopted by the Medicaid and NJ FamilyCare programs. (See 10:51-2.23 ); and

5. Erectile dysfunction drugs for individuals who are registered on New Jersey's Sex Offender Registry.

N.J. Admin. Code § 10:51-2.11

Amended by 48 N.J.R. 2785(a), effective 12/19/2016