N.J. Admin. Code § 10:51-1.10

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:51-1.10 - Provider's usual and customary charge or advertised charge

(a) The provider's usual and customary charge or advertised charge is an element considered in the calculation of the basis of payment for legend drugs (see 10:51-1.5, Basis of payment).

(b) The usual and customary charge to the Medicaid or NJ FamilyCare program is defined as the amount a provider charges the general public for a prescription for the same drug product (same NDC number) in the same quantity as the prescription being dispensed to a Medicaid or NJ FamilyCare beneficiary. "Usual and customary charge" means the actual charge made to the majority (51 percent) of the total patient population served by the individual pharmacy.

1. The provider shall not charge the programs more than would be charged to a cash customer when the general public, including private third party plans, accounts for more than 50 percent of a provider's total prescription volume.

i. In the event Medicaid, NJ FamilyCare and/or PAAD represent more than 50 percent of a provider's total prescription volume, then, for reimbursement purposes, the provider's usual and customary charge may be considered the amount the programs would reimburse for the same services.

N.J. Admin. Code § 10:51-1.10

Amended by R.1998 d.488, effective 9/21/1998.
See: 30 New Jersey Register 2169(b), 30 New Jersey Register 3538(a).
In (b), inserted references to NJ KidCare throughout.
Amended by R.2004 d.26, effective 1/20/2004.
See: 35 New Jersey Register 3788(a), 36 New Jersey Register 558(a).
In (b), substituted "NJ FamilyCare" for "NJ KidCare" throughout.