N.J. Admin. Code § 10:58-2.17
Current through Register Vol. 57, No. 1, January 6, 2025
Section 10:58-2.17 - Pharmaceutical services; drugs prescribed and administered by a CNM(a) All covered pharmaceutical services provided under the New Jersey Medicaid/NJ FamilyCare programs shall be provided to Medicaid/NJ FamilyCare-Plan A fee-for-service beneficiaries within the scope of N.J.A.C. 10:49, Administration chapter; N.J.A.C. 10:51, Pharmaceutical Services; and N.J.A.C. 10:58, Certified Nurse Midwifery Services.(b) All drugs shall be prescribed drugs. (See definition of "prescribed drugs" in N.J.A.C. 10:58-1.3.)(c) The New Jersey Medicaid/NJ FamilyCare programs shall reimburse Medicaid/NJ FamilyCare participating pharmacies for pharmaceutical services prescribed by the certified nurse midwife if all the requirements of the New Jersey Medicaid/NJ FamilyCare-Plan A fee-for-service programs for pharmaceutical services are met.(d) The following requirements shall be met for the following services: | Covered pharmaceutical services | N.J.A.C. 10:51-1.11 |
| Prior-authorized services | N.J.A.C. 10:51-1.13 |
| Quantity of medication dispensed | N.J.A.C. 10:51-1.14 |
| Dosage and directions | N.J.A.C. 10:51-1.15 |
| Telephone-rendered original prescription | N.J.A.C. 10:51-1.16 |
| Changes or additions to the original prescription | N.J.A.C. 10:51-1.17 |
| Prescription refill | N.J.A.C. 10:51-1.18 |
| Prescription Drug Price and Quality |
| Stabilization Act | N.J.A.C. 10:51-1.19 |
| Non-proprietary or generic dispensing | N.J.A.C. 10:51-1.9 |
| Drug Efficacy Study Implementation (DESI) | N.J.A.C. 10:51-1.20 |
| N.J.A.C. 10:51, |
| Appendix A |
| Drug Manufacturers' Rebate Agreement | N.J.A.C. 10:51-1.21 |
(e) Diabetic testing materials, including blood glucose reagent strips, urine monitoring strips, tapes, tablets, and lancets, may also be reimbursed. Electronic blood glucose monitoring devices or other devices used in the monitoring of blood glucose levels are considered medical supplies and are covered services by the Medicaid/NJ FamilyCare-Plan A fee-for service programs if they meet all applicable requirements of the New Jersey Medicaid/NJ FamilyCare programs. These services may require prior authorization from the Medical Assistance Customer Center (MACC). (See Medical Supplier Services Chapter, N.J.A.C. 10:59.)(f) The New Jersey Medicaid/NJ FamilyCare fee-for-service programs shall reimburse the certified nurse midwife for certain approved drugs administered by inhalation, intradermally, subcutaneously, intramuscularly or intravenously in the office or home, as follows: 1. Certified nurse midwife-administered medications shall be reimbursed directly to the certified nurse midwife under certain situations. (See N.J.A.C. 10:58-3 for a listing of HCPCS procedure codes, "J" codes and applicable 3rd level procedure codes.) i. An office or home visit (when the criteria for an office or home visit is met) and the procedure code for the method of drug administration may be billed in conjunction with a "J" code. The HCPCS 90782, 90784, 90785 and 90799 may be billed for intradermal, subcutaneous, intramuscular, or intravenous drug administration, respectively.ii. The New Jersey Medicaid/NJ FamilyCare programs have assigned HCPCS procedure codes and maximum fee allowances at N.J.A.C. 10:58-3.4 and 3.5 for specific drugs. Reimbursement to the certified nurse midwife for these specific drugs shall be based on the Average Wholesale Price (AWP) of a single dose of an injectable or inhalation drug, or the CNM's acquisition cost, whichever is less.iii. Unless otherwise indicated in N.J.A.C. 10:58-3, or (f)1iv through vii below, the Medicaid/NJ FamilyCare fee-for-service maximum fee allowance is determined based on the AWP per unit which equals one cubic centimeter (cc) or milliliter (ml) of drug volume for each unit. For drug vials with a volume equal to one cubic centimeter (cc) or milliliter (ml), the Medicaid/NJ FamilyCare fee-for-service maximum fee allowance shall be based on the cost per vial.iv. When a certified nurse midwife 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 its administration. In these situations, there is no reimbursement for a certified nurse midwife's office or home visit. If, in addition to the certified nurse midwife's administration of a drug, the criteria of an office or home visit are met, the cost of the drug and administration may, if medically indicated, be reimbursed in addition to the visit.v. No reimbursement will be made for vitamins, liver or iron injections or combination thereof, except in laboratory-proven deficiency states requiring parenteral therapy.vi. No reimbursement will be made for drugs or vaccines supplied free to the CNM, for placebos, or for any injections containing amphetamines or derivatives thereof.vii. No reimbursement will be made for injection given as a preoperative medication or as a local anesthetic which is part of an operative or surgical procedure, since this injection would normally be included in the prescribed fee for such a procedure.2. When a drug required for administration has not been assigned a "J" code or Level III HCPCS procedure code, the drug shall be prescribed and obtained from a pharmacy which directly bills the New Jersey Medicaid/NJ FamilyCare fee-for-service programs. In this situation, the certified nurse midwife shall bill only for the administration of the drug using HCPCS 90782, 90784, 90788 and 90799.3. Reimbursement for immunization procedure codes includes the cost of the administration of the immunization.(g) 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.(h) For Hepatitis B vaccine, coverage is available for post exposure prophylaxis and for vaccination of individuals in selected high risk groups, regardless of age, in accordance with the criteria defined by the Centers for Disease Control. In all cases, the need for this vaccination shall be fully documented in the medical record by the certified nurse midwife. (See N.J.A.C. 10:58-3.5 and 3.6, respectively, for specific descriptions and qualifiers associated with each Level III procedure code.)N.J. Admin. Code § 10:58-2.17
Amended by R.2001 d.204, effective 6/18/2001.
See: 33 N.J.R. 1160(a), 33 N.J.R. 2188(a).
In (a), inserted a reference to NJ FamilyCare and substituted "/NJ FamilyCare-Plan A fee-for-service beneficiaries" for "recipients"; in (c) and (e), inserted references to NJ FamilyCare and NJ FamilyCare-Plan A fee-for-service; in (f), inserted references to NJ FamilyCare and NJ FamilyCare fee-for-service throughout.
Amended by R.2006 d.338, effective 9/18/2006.
See: 38 N.J.R. 2003(a), 38 N.J.R. 3900(a).
In (e), substituted "Medical Assistance Customer Center (MACC)" for "Medicaid District Office (MDO)".