N.J. Admin. Code § 10:167-4.2

Current through Register Vol. 57, No. 1, January 6, 2025

Section 10:167-4.2 - Principles of reimbursement to participating pharmacies

(a) Reimbursement for PAAD prescriptions shall be made only to pharmacies located in New Jersey except as indicated in (b)1 below and operating under a valid permit from the Board of Pharmacy of the State of New Jersey. In order to become an approved provider, such a pharmacy must file an application and agreement of participation, which must be approved by the Division of Medical Assistance and Health Services of the Department of Human Services. The application shall contain the pharmacy's NSC Supplier Number issued by the National Supplier Clearinghouse (NSC) or other appropriate agent of the Centers for Medicare and Medicaid Services (CMS) or a statement that the pharmacy has applied for an NSC Supplier Number to enroll as a Medicare Part B supplier. A copy of one of the proofs of enrollment listed in N.J.A.C. 10:167A-1.3(c)2 shall be attached to the application. The pharmacy shall also complete and return the Electronic Data Interchange (EDI) Enrollment Form attached to the application.

(b) No reimbursement shall be made to an unlicensed pharmacy or to a pharmacy located in another state or country, except as follows:

1. The Department shall have the authority to coordinate benefits with any voluntary mail-order prescription drug program or specialty pharmacy in a Medicare Part D plan provider network, or a mail order prescription drug program required by a PAAD beneficiary's primary payer.

(c) Reimbursement on behalf of PAAD beneficiaries shall be made directly to the participating pharmacies and shall be for the reasonable cost of prescription drugs of beneficiaries as determined by the Commissioner, Department of Human Services, which exceeds the PAAD co-payment per prescription.

N.J. Admin. Code § 10:167-4.2

Amended by R.1993 d.155, effective 4/5/1993.
See: 24 N.J.R. 4328(a), 25 N.J.R. 1514(a).
Amended by R.2003 d.248, effective 6/16/2003.
See: 34 N.J.R. 3456(a), 35 N.J.R. 2642(a).
Amended by R.2009 d.16, effective 1/5/2009.
See: 40 N.J.R. 4479(a), 41 N.J.R. 221(a).
Amended by R.2009 d.293, effective 10/5/2009.
See: 41 N.J.R. 1637(a), 41 N.J.R. 3804(a).