MedicaidCoverageHigh impact
Newsletter Vol. 21, No.15
New Jersey Medicaid·NJ · Pharmacy·Pharmacy
Effective date
Jul 1, 2011
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJFC) and related state pharmacy programs are discontinuing coverage of Medicare Part D copayments effective July 1, 2011, and eliminating coverage for drugs not on Medicare Part D (except benzodiazepines, barbiturates, smoking cessation products, and legend vitamins). Simultaneously, pharmacy reimbursement methodology is shifting from AWP-based calculations to WAC, SUL/FUL, or acquisition cost-based models effective September 1, 2011. Billing teams must update claim submission logic and collect copayments from beneficiaries.
Action Required
By July 1, 2011: Billing team must (1) update pharmacy billing system to STOP submitting Medicare Part D copayments to NJFC/Medicaid for reimbursement; (2) configure point-of-sale systems to allow pharmacists to collect copayments directly from NJFC/Medicaid beneficiaries; (3) implement drug coverage edit rules to reject non-Medicare Part D covered drugs except benzodiazepines, barbiturates, smoking cessation products, and legend vitamins. By September 1, 2011: Update reimbursement calculation engine to use WAC-1% + $3.73-$3.99 dispensing fee, SUL/FUL + dispensing fee, or acquisition cost + professional fee (whichever is lesser) in place of AWP-based pricing. Remove AWP lookup dependencies. Update claim adjudication rules to exclude these reimbursement changes when New Jersey is secondary payer to Medicare Part D. Pharmacy staff must begin submitting acquisition cost data to state GHS system to support SUL rate setting. Failure to implement will result in claim denials, overpayments, or recoupments from the state.