Traditional MedicareAdministrativeHigh impact
Senior Services News Vol. 29, No. 01
New Jersey Medicaid·NJ·Pharmacy
Effective date
Mar 15, 2026
We identified it
Jun 20, 2026
Summary
New Jersey PAAD/Senior Gold pharmacy claims will be denied starting March 15, 2026 if Medicare Part D patient responsibility amounts exceed the $2,100 annual out-of-pocket maximum or LIS copayment limits ($5.10 generic, $12.65 brand). Pharmacies must ensure proper secondary billing to avoid new error codes 2358 and 2359.
Action Required
By March 15, 2026: Pharmacy billing teams must update claims processing systems to ensure NCPDP Field 352-NQ 'Other Payer-Patient Responsibility Amounts' never exceed $2,100 annually for Medicare Part D or $5.10/$12.65 for LIS beneficiaries when billing PAAD/Senior Gold as secondary. Configure system to track cumulative out-of-pocket amounts and prevent submission of claims that would trigger error codes 2358 or 2359. Verify proper billing sequence: 1) Medicare Part D primary, 2) PAAD/SG secondary, 3) Medicare Prescription Payment Plan if applicable.