MedicaidReimbursementHigh impact
Newsletter Vol. 19, No. 48
New Jersey Medicaid·NJ · Pharmacy·Reimbursement
Effective date
Sep 25, 2009
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid revised Maximum Allowable Cost (MAC) pricing for pharmaceutical services effective September 25, 2009. Two drugs had MAC suspended due to generic unavailability, 15 drugs received price decreases, and 4 new drug products were added to the Federal Upper Limits. Billing teams must update drug pricing tables and reimbursement systems immediately.
Action Required
By September 25, 2009: Billing team must immediately update all pharmacy billing systems and MAC pricing tables in the following ways: (1) Remove Erythromycin 0.5% Ointment Ophthalmic and Metoprolol Succinate Extended Release from reimbursable drug list—claims for these will be denied. (2) Update pricing in billing software for all 15 drugs with price decreases (Amiodarone, Benzonatate, Betamethasone/Clotrimazole, Citalopram, Clarithromycin, Clobetasol Propionate, Methylphenidate, Naproxen, Ofloxacin, and Tizanidine) to reflect new MAC prices per unit/quantity. (3) Add 4 new drug products to formulary: Amoxicillin/Clavulanic Acid (suspension and tablets in multiple strengths) and Clobetasol Propionate Emollient Base cream with corresponding MAC prices. Update pharmacy claims processing rules and staff training on new pricing. Verify all claims processed on or after September 25, 2009 reflect updated MAC amounts, or claims will be subject to audit and recoupment. Retain this newsletter for reference during future audits.