MedicaidCoverageHigh impact
Newsletter Vol. 29, No.17
New Jersey Medicaid·NJ · Pharmacy·Pharmacy
Effective date
Oct 1, 2019
We identified it
Jun 20, 2026
Summary
New Jersey has implemented guidelines for automatic prescription drug refill programs under NJ FamilyCare Medicaid, PAAD, Senior Gold, and ADDP. Prescriptions can only be auto-refilled when explicitly requested, limited to maintenance drugs, with mandatory annual re-authorization and written documentation. Pharmacies must verify medical necessity and reverse payments within 14 days for prescriptions not received by beneficiaries.
Action Required
Immediately: Billing team must update pharmacy claims processing procedures to enforce auto-refill compliance. Specific actions: (1) Implement system rules to reject auto-refill claims lacking explicit beneficiary/prescriber/responsible party authorization; (2) Require pharmacy staff to verify annual re-authorization with written documentation retained for 10 years on file; (3) Configure billing system to limit auto-refills to maintenance drugs only (chronic conditions: hypertension, heart disease, asthma, diabetes); (4) Establish 14-day tracking mechanism to reverse and recover any payments for prescriptions not received by beneficiary/responsible party; (5) For skilled nursing facilities, restrict auto-refills to unit-dose medications with facility nurse/authorized agent requests only. Consequences of non-compliance: Claims subject to state recovery actions and potential fraud investigation by Medicaid Fraud Division. Contact DXC Technology Provider Services Unit at 1-800-776-6334 for questions.