New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 58A - ADVANCED PRACTICE NURSE SERVICES
Subchapter 2 - PROVISION OF SERVICES
Section 10:58A-2.4 - Pharmaceutical services-drugs prescribed and/or administered by an APN

Universal Citation: NJ Admin Code 10:58A-2.4

Current through Register Vol. 56, No. 18, September 16, 2024

(a) All covered pharmaceutical services provided by APNs under the New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall be prescribed and administered in accordance with: 13:37-7.9 and 7.10; 10:49; 10:51; and this chapter.

(b) The Pharmaceutical Services manual, N.J.A.C. 10:51, sets forth the provisions for covered and non-covered pharmaceutical services, prior authorization, quantity of medication, administration of drugs, pharmaceutical dosage and directions, telephone-rendered original prescriptions, changes or additions to the original prescription, non-proprietary or generic dispensing, and prescription refill.

(c) The Medicaid/NJ FamilyCare fee-for-service programs will reimburse the clinical practitioner directly for the cost of the drugs described at 10:58A-4.3.

(d) The Medicaid/NJ FamilyCare program will reimburse APNs for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office, home or independent clinic setting according to the following reimbursement methodologies. See N.J.A.C. 10:58A-4 for a listing of HCPCS procedure codes.

1. When an APN office or home visit is made for the sole purpose of administering a drug, reimbursement shall be limited to the cost of the drug and/or its administration. In these situations, there is no reimbursement for an APN's office or home visit. If, in addition to the APN's administration of a drug, the criteria of an office or home visit are met, the cost of the drug and/or administration may, if medically indicated, be reimbursed in addition to the visit.

(e) The drug administered must be consistent with the diagnosis and conform to accepted medical and pharmacological principles in respect to dosage frequency and route of administration.

(f) In order for APN-administered drugs to be reimbursed by the Medicaid/NJ FamilyCare program, manufacturers must have in effect all rebate agreements required or directed pursuant to all applicable State and Federal laws and regulations. To confirm that a manufacturer has complied with such rebate provisions and that a particular drug manufactured by it is covered, an APN may consult the website at: https://http://www.njmmis.com/ndcLookup.aspx.

(g) APNs shall report the 11-digit National Drug Code (NDC), quantity of the drug administered or dispensed, and a two-digit qualifier identifying the unit of measure for the medication on the claim when requesting reimbursement. The labeler code and drug product code of the actual product dispensed must be reported on the claim form.

1. The package size code (that is, positions No. 10 and 11 of the NDC) reported may differ from the stock package size used to fill the prescription. Acceptable units of measure are limited to: F2 (international unit); GM (gram); ML (milliliter); and UN (unit/each).

(h) No reimbursement will be made for vitamins, liver or iron injections or combination thereof, except in laboratory-proven deficiency states requiring parenteral therapy.

(i) No reimbursement will be made for drugs or vaccines supplied free to the APN, for placebos, or for any injections containing amphetamines or derivatives thereof.

(j) No reimbursement will be made for injection given as a preoperative medication or as a local anesthetic that is part of an operative or surgical procedure.

(k) Where a drug required for administration has not been assigned a HCPCS procedure code, the drug shall be prescribed and dispensed by a pharmacy that directly bills the Medicaid/NJ FamilyCare program. In this situation, the APN shall bill only for the administration of the drug.

Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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