N.J. Admin. Code § 10:167A-1.11

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

Section 10:167A-1.11 - Compounded prescriptions

(a) Compounded prescriptions may be reimbursed by the PAAD program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and are dispensed by approved providers.

(b) Claims for compounded prescriptions shall be electronically submitted to the fiscal agent through a point-of-sale (POS) claim adjudication system approved by the PAAD program. (See N.J.A.C. 10:167A-1.27).

1. A compounded prescription is indicated by the provider by the use of the "compound drug" indicator field in the EMC claim format.

(c) Reimbursement for compound prescriptions shall be:

1. In accordance with N.J.A.C. 10:167A-1.7 plus a dispensing fee, as described in N.J.A.C. 10:167A-1.9; or

2. A provider's usual and customary charge.

(d) The maximum charge for a compounded prescription must not exceed the limits set forth in 10:167A-1.16

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

1. All legend ingredients that are contained in compounded prescriptions shall be covered by the PAAD program in accordance with N.J.A.C. 10:167A-1.14 and 1.15.

2. Compounded prescriptions containing drugs not eligible for reimbursement under N.J.A.C. 10:167A-1.15 are not covered.

N.J. Admin. Code § 10:167A-1.11

Amended by R.1996 d.146, effective 3/18/1996 (operative April 1, 1996).
See: 27 N.J.R. 4566(a), 28 N.J.R. 1526(a).
Amended by R.1998 d.464, effective 9/8/1998.
See: 30 N.J.R. 2197(a), 30 N.J.R. 3309(a).
Recodified from N.J.A.C. 8:83C-1.9 and amended by R.2003 d. 248, effective 6/16/2003.
See: 34 N.J.R. 3456(a), 35 N.J.R. 2642(a).
Amended N.J.A.C. references throughout. Former N.J.A.C. 8:83C-1.11, Provider's usual and customary charge or advertised charge, recodified to N.J.A.C. 8:83C-1.13.

Amended by 49 N.J.R. 446(a), effective 3/6/2017