MedicaidReimbursementHigh impact
Newsletter Vol. 20, No. 11
New Jersey Medicaid·NJ · Pharmacy·Pharmacy
Effective date
Jul 1, 2010
We identified it
Jun 20, 2026
Summary
New Jersey updated pharmacy reimbursement rates for FFS programs effective July 1, 2010 and January 1, 2011. Brand-name drugs will be reimbursed at AWP minus 17.5% or usual and customary charge (whichever is less). Generic drugs add MAC pricing comparison (July 1) and State Upper Limit (SUL) pricing at 150% of lowest SWAC (January 1). Changes do not apply when NJ is secondary to Medicare Part D.
Action Required
By July 1, 2010: Billing team must update pharmacy billing system to apply new reimbursement formula: brand-name drugs use lesser of (AWP minus 17.5%) or usual/customary charge. By January 1, 2011: Update system again to add MAC and State Upper Limit (SUL) pricing comparisons for generic drugs—reimbursement uses the LOWEST of four values: (AWP minus 17.5%), MAC, SUL (calculated at 150% lowest SWAC), or usual/customary charge. Verify all claims for NJ FamilyCare/Medicaid, Work First NJ/GA, PAAD, Senior Gold, AIDS Drug Distribution, and CF programs apply correct formulas. Contact Molina Medicaid Solutions (800-776-6334) for SUL pricing lists before January 1, 2011 implementation. Claims processed with incorrect rates will be denied or require adjustment.