N.J. Admin. Code § 10:51-2.8

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

Section 10:51-2.8 - Compounded prescriptions

(a) Compounded prescriptions may be reimbursed by the Medicaid or NJ FamilyCare program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved 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.

(b) Claims for compounded prescriptions may be manually or electronically submitted to the fiscal agent through a point-of-sale (POS) claims adjudication system approved by the Division. (See 10:51-2.22)

1. A compounded prescription is indicated by the provider by the use of the "compounded drug" indicator field on a manual claim or in a similar field in the EMC claim format.

(c) Reimbursement for compounded prescriptions shall be based on the cumulative cost of the active ingredient(s), as described in 10:51-2.5, and/or pharmaceutical excipient(s).

(d) For compounded prescriptions without an active ingredient(s), reimbursement is based on the cumulative cost of the pharmaceutical excipient(s).

1. For pharmaceutical excipients costing less than $ 0.25, the provider may charge Medicaid or NJ FamilyCare $ 0.25 for each ingredient.

2. Reimbursement for compounded prescriptions without an active ingredient(s) shall be provided under a common drug code assigned by DMAHS.

(e) Reimbursement for compounded prescriptions submitted manually or as an EMC claim is calculated based on the ingredient cost, as described in 10:51-2.5, of the most costly active ingredient.

(f) The maximum charge for a compounded prescription must not exceed the limits set forth in 10:51-2.12.

(g) Restrictions on payments for compounded prescriptions are as follows:

1. All legend and non-legend (OTC) ingredients which are contained in compounded prescriptions must be covered by a manufacturer rebate agreement (see 10:51-2.19) . If the labeler code of any single ingredient is not manufactured by an approved manufacturer, the compounded prescription is not covered. Chemical ingredients without NDC codes are excluded.

2. All non-legend ingredients which are contained in compounded prescriptions shall be among those covered by the Medicaid or NJ FamilyCare program. If a non-legend drug is not listed as covered in 10:51-2.10, the compounded prescription shall not be covered.

3. All legend ingredients which are contained in compounded prescriptions shall be among those covered by the Medicaid or NJ FamilyCare program. If a legend drug is a DESI (Drug Efficacy Study Implementation, see 10:51-2.18) drug, the compounded prescription shall not be covered.

4. Compounded prescriptions containing drugs not eligible for reimbursement under 10:51-2.11 shall not be covered.

N.J. Admin. Code § 10:51-2.8

Amended by R.1996 d.146, effective 3/18/1996 (operative April 1, 1996).
See: 27 New Jersey Register 4566(a), 28 New Jersey Register 1526(a).
Amended by R.1998 d.488, effective 9/21/1998.
See: 30 New Jersey Register 2169(b), 30 New Jersey Register 3538(a).
Inserted references to the NJ KidCare throughout; and in (b), substituted a reference to the Division for a reference to the Medicaid program.
Amended by R.2004 d.26, effective 1/20/2004.
See: 35 New Jersey Register 3788(a), 36 New Jersey Register 558(a).
Rewrote (g) and substituted "NJ FamilyCare" for "NJ KidCare" throughout.