Medicare AdvantagePrior AuthHigh impact
Newsletter Vol. 16, No. 03
New Jersey Medicaid·NJ · Pharmacy·Reimbursement
Effective date
Mar 1, 2006
We identified it
Jun 20, 2026
Summary
This policy clarifies Medicare Part D payment responsibilities for dual-eligible beneficiaries in New Jersey. Pharmacies must submit claims first to Medicare Prescription Drug Plans (PDPs), then submit secondary claims to the state fiscal agent (Unisys) for coinsurance/copay. Pharmacies are prohibited from billing dual eligibles directly for cost-sharing. The policy also establishes which wraparound drugs require prior authorization under Part D plans.
Action Required
Immediately: Pharmacy billing team must implement the following: (1) Update billing system to ensure all claims for NJ FamilyCare/Medicaid dual-eligible clients are submitted FIRST to the client's Medicare Part D plan, not to the state; (2) Configure system to submit secondary claims to Unisys (State's fiscal agent) with the correct PDP Payer ID Code in NCPDP Field 340-7C (Coordination of Benefits segment); (3) Remove any direct billing to dual-eligible patients for coinsurance/copay amounts—this is prohibited; (4) For non-Part D payers (commercial drug plans), report Insurance Carrier Code for PBM in Field 340-7C using codes from Fiscal Agent Billing Supplement Appendix C; (5) Implement prior authorization requirements: drugs listed in Table 2 (e.g., nimodipine, fentanyl lollipop, methotrexate, all antibiotics, SSRIs, anticonvulsants) require prior auth; drugs in Table 1 do not; (6) Train pharmacy staff to contact client's PDP if copay amounts are incorrect; escalate urgent issues to Medicare pharmacy assistance line (1-866-835-7595). Failure to follow this process will result in claim denials and compliance violations.