MedicaidPrior AuthMedium impact
Newsletter Vol. 11, No. 80
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Oct 1, 2001
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid and NJ FamilyCare now allow non-participating pharmacies to dispense prescriptions that are eligible for payment by another insurance plan, provided a participating pharmacy is located more than 5 miles away. Non-participating pharmacies must obtain prior authorization from First Health Services and report it in NCPDP Field 416 using a specific format (50 + PA number).
Action Required
Immediately: Pharmacy billing staff must implement procedures to request prior authorization from First Health Services (1-877-888-2939) for non-participating pharmacy claims when a participating pharmacy is more than 5 miles from the beneficiary's residence. Update billing system to correctly populate NCPDP Field 416 (PA/MC Code and Number) with value '50' in the first two positions followed by the PA number issued by First Health Services. Train staff to distinguish between the new format (50 + PA number) and the existing format (10 + PA number). Verify that non-participating pharmacies only use this procedure when distance requirements are met to avoid misuse of the override. Monitor compliance to ensure the procedure is not used to avoid reporting other insurance payments to the state.