MedicaidCoverageHigh impact
Newsletter Vol. 12, No. 16
New Jersey Medicaid·NJ · Pharmacy, Infectious Disease, Oncology +2 more·Provider Notice
Effective date
Mar 1, 2002
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid, NJ FamilyCare, PAAD, ADDP, and CF pharmacy programs are implementing updated Prospective Drug Utilization Review (PDUR) standards effective March 1, 2002. Changes include revised maximum daily dosage limits for Rofecoxib (Vioxx) and non-weight-based oral chemotherapy drugs, new drug-drug interaction rules for HIV/AIDS medications and ACE inhibitors, age/sex restrictions for Serafem, and retrospective review standards for specific drug combinations. Pharmacy claims submitted with service dates on or after March 1, 2002 will be subject to these new automated edits and may be rejected if dosages exceed the updated standards.
Action Required
By February 28, 2002: Pharmacy providers and dispensing locations must update their pharmacy billing systems to reflect the new PDUR standards. SPECIFIC ACTIONS: (1) Update maximum daily dosage validation rules in billing software for Rofecoxib (Vioxx 12.5mg, 25mg, 50mg, 25mg/5ml suspension) and all listed non-weight-based oral chemotherapy drugs to use the new dosage limits (quotient of Metric Quantity/Days Supply); (2) Add new drug-drug interaction edits (Error Code 869) to prevent claims from dispensing HIV/AIDS drugs in combination with specified conflict drugs (e.g., Agenerase with Bepridil, Rifampin, Zocor, etc.); (3) Configure ACE inhibitor interaction rule (Error Code 916) to flag therapeutic duplication when Type 1 and Type 2 ACE inhibitors are prescribed together; (4) Implement age/sex restriction for Serafem to restrict to female patients aged 18-999; (5) Set up retrospective review monitoring (Error Code 870) for Cytovene/Retrovir, Zerit/Videx, and Videx combination interactions. RESPONSIBILITY: Pharmacy billing team, IT/systems staff, and pharmacy software vendors must make changes in the billing system. WHO TO CONTACT: Reach out to First Health Services Customer Service at (877) 266-3589 or DMAHS Chief of Pharmaceutical Services at (609) 588-2724 for implementation support. CONSEQUENCES: Claims for Medicaid, NJ FamilyCare FFS, PAAD, ADDP, and CF programs submitted on or after March 1, 2002 that exceed the new dosage standards or contain flagged drug interactions will be rejected at point-of-sale or subject to retrospective review denial. Pharmacists must use the Medical Exception Process (MEP) to override edits when clinically appropriate (see Newsletter Volume 9, No. 67 for MEP details).