MedicaidReimbursementHigh impact
Newsletter Vol. 15, No. 12
New Jersey Medicaid·NJ · Pharmacy·Medical Policy
Effective date
Jul 1, 2005
We identified it
Jun 20, 2026
Summary
New Jersey's State Fiscal Year 2006 Appropriations Act introduces three pharmacy coverage changes effective July 1, 2005: (1) Medicaid/WFNJ/GA physician-administered drugs reimbursed at AWP less 12.5% or acquisition cost (whichever is lower); (2) refill requirements increased from 75% to 85% days supply exhausted for non-WFNJ/GA prescriptions (WFNJ/GA remains 90%); (3) new claims edit prevents simultaneous dispensing of methadone and narcotic prescriptions, with narcotic claims denied if co-dispensed.
Action Required
REQUIREMENTS: By July 1, 2005: Billing team must immediately update pharmacy billing system to: (1) Change reimbursement calculation for Level II HCPCS physician-administered drugs (Medicaid/WFNJ/GA) to AWP less 12.5% or practitioner acquisition cost, whichever is lower; (2) Increase refill edit thresholds from 75% to 85% days supply exhausted for all non-WFNJ/GA prescriptions, maintaining 90% threshold for WFNJ/GA prescriptions; (3) Activate methadone-narcotic co-dispensing edit to deny all narcotic prescription claims when methadone is active on the same claim or clinic record. Update pharmacy staff and prescribers on new refill requirements. Monitor claims for increased denials related to the methadone-narcotic edit and contact prescribers for narcotic prescription adjustments. Failure to implement will result in improper reimbursement, denied claims, and potential audit findings.