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
Universal Citation: NJ Admin Code 10:51-1.10
Current through Register Vol. 56, No. 18, September 16, 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.
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