MedicaidReimbursementHigh impact
Newsletter Vol. 21, No.11
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
May 18, 2011
We identified it
Jun 20, 2026
Summary
New Jersey is implementing State Upper Limit (SUL) prices for multi-source drugs effective May 18, 2011. Pharmacy reimbursement for these drugs will now be calculated as the lesser of: AWP minus 17.5%, federal upper limit, SUL price, or usual and customary charge. Pharmacies must review proposed SUL prices and can dispute prices below their acquisition costs through a formal process.
Action Required
By May 18, 2011: Billing and pharmacy teams must implement new drug reimbursement calculation methodology in billing systems to automatically apply the four-tier pricing hierarchy (AWP-17.5%, FUL, SUL, or usual and customary—whichever is lowest). By May 2, 2011: Pharmacy staff must review proposed SUL prices on www.njmmis.com and identify any drugs with SUL prices below actual acquisition costs. For any problematic pricing, pharmacy staff must complete and fax the 'Prescription(s) Reimbursed Below Cost Research Request Form' to GHS at 1-877-350-2808 before claims are processed. Staff should monitor the active SUL list starting May 18, 2011 on www.njmmis.com and after June 1, 2011 on www.njsul.com. Update all drug reimbursement protocols and staff training materials to reflect new pricing rules. Failure to implement correct pricing will result in claim denials or overpayments.