MedicaidCoverageHigh impact
Newsletter Vol. 19, No. 38
New Jersey Medicaid·NJ · Pharmacy·Pharmacy
Effective date
Jul 1, 2009
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid (NJ FamilyCare/NJFC and Work First New Jersey/WFNJ) is implementing significant pharmacy benefit changes effective July 1, 2009. Drug reimbursement will be calculated as the lower of AWP minus 16% or MAC price. Coverage is eliminated for erectile dysfunction drugs, hydrocodone/chlorpheniramine combinations, and lipase inhibitors. OTC legend drugs are no longer covered for members 21+, and cough/cold preparations for adults 21+ require documented antibiotic use within 7 days or diagnosis of acute respiratory infection/chronic pulmonary disease.
Action Required
By July 1, 2009: (1) Billing team must update pharmacy billing system to calculate reimbursement using lower of AWP-16% or FFPUL/MAC price for all NJ Medicaid claims; (2) Implement claim rejection rules in billing software to deny coverage for erectile dysfunction drugs, hydrocodone/chlorpheniramine products, and lipase inhibitors for NJ Medicaid members; (3) Configure system to deny OTC legend drugs for members 21+ on NJ Medicaid; (4) For cough/cold legend products on NJ Medicaid members 21+, billing/pharmacy staff must verify and document either antibiotic use in prior 7 days or diagnosis of acute respiratory infection/chronic pulmonary disease before submission—antibiotic claims must be submitted to Unisys before cough/cold claims on same service date; (5) Train pharmacy staff and providers on new coverage restrictions and documentation requirements; (6) Update internal policies and claim submission procedures. Contact Unisys Provider Services at 1-800-776-6334 with questions. Failure to implement will result in claim denials and payment delays.