Current through Register Vol. 56, No. 18, September 16, 2024
(a) Compounded prescriptions may be reimbursed by the Medicaid and NJ FamilyCare programs. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved pharmacy 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 10:51-1.25) .
1. A compounded prescription is indicated by the provider by the use of the "compound drug" indicator field on a manual claim or in a similar field in the EMC claim format.
(c) Reimbursement for compounded prescriptions shall not exceed the lower of:
1. The cumulative cost of the active ingredient(s), as described in 10:51-1.5, and/or pharmaceutical excipient(s), plus a dispensing fee, as described in 10:51-1.7; or
2. A provider's usual and customary charge.
(d) For compounded prescriptions without an active ingredient(s), reimbursement is based on the cumulative cost of the pharmaceutical excipient(s), unless otherwise specified by NCPDP standards, version 5.1 and version 1.1 as amended and supplemented, incorporated herein by reference. The Council's address is 4201 North 24th Street, Suite 365, Phoenix, Arizona 85016.
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 10:51-1.5, of the most costly active ingredient, plus a dispensing fee, as described in 10:51-1.7.
1. For compounded prescriptions without an active ingredient(s), reimbursement is based on (d) above, plus a dispensing fee, as described in 10:51-1.7.
(f) The maximum charge for a compounded prescription must not exceed the limits set forth in 10:51-1.15.
(g) Restriction in payments for compounded prescriptions are as follows:
1. All legend and nonlegend (OTC) ingredients which are contained in compounded prescriptions must be covered by a manufacturer rebate agreement (see 10:51-1.22) . 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 must be covered by the Medicaid and NJ FamilyCare program. If a non-legend drug is not listed as covered in 10:51-1.11, the compounded prescription is not covered.
3. All legend ingredients which are contained in compounded prescriptions must be covered by the Medicaid or NJ FamilyCare fee-for-service programs. If a legend drug is a DESI (Drug Efficacy Study Implementation, see 10:51-1.20) drug, the compounded prescription is not covered.
4. Compounded prescriptions containing drugs not eligible for reimbursement under 10:51-1.13 are not covered.
