N.J. Admin. Code § 10:167C-1.9

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

Section 10:167C-1.9 - Compounded prescriptions

(a) Compounded prescriptions may be reimbursed by the Program. Compounded prescriptions are extemporaneously prepared mixtures of an active ingredient or ingredients and/or a pharmaceutical excipient or excipients and are dispensed by approved providers.

1. Acceptable pharmaceutical excipients which do not contribute therapeutically to a compound, include, but are not limited to hydrophilic ointment, petrolatum, aquifer, 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) claim adjudication system approved by the Program. (See N.J.A.C. 10:167C-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 Electronic Media Claims (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 N.J.A.C. 10:167C-1.5, and/or pharmaceutical excipient(s), plus a dispensing fee, as described in N.J.A.C. 10:167C-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).

1. For pharmaceutical excipients costing less than $ 0.25, the provider may charge Senior Gold $ 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 N.J.A.C. 10:167C-1.5, of the most costly active ingredient, plus a dispensing fee, as described in N.J.A.C. 10:167C-1.7.

1. For compounded prescriptions without an active ingredient(s), reimbursement is based on (d) above, plus a dispensing fee, as described in N.J.A.C. 10:167C-1.7.

(f) The maximum charge for a compounded prescription must not exceed the limits set forth in N.J.A.C. 10:167C-1.14.

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

1. Prescriptions must be covered by the Program. If a legend drug is a DESI (Drug Efficacy Study Implementation, see N.J.A.C. 10:167C-1.20) drug, the compounded prescription is not covered.

2. Compounded prescriptions containing drugs not eligible for reimbursement under N.J.A.C. 10:167C-1.13 are not covered.

N.J. Admin. Code § 10:167C-1.9