MedicaidPrior AuthMedium impact
Newsletter Vol. 11, No. 51
New Jersey Medicaid·NJ · Pharmacy, Infectious Disease·Provider Notice
Effective date
Jul 1, 2001
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid is implementing enhanced prior authorization requirements for somatropin (rDNA origin) injections used to treat HIV-associated wasting syndrome, effective July 1, 2001. Pharmacists must obtain prior authorization from First Health Services before dispensing, with claims subject to error code 537 for maximum daily dosage violations. Initial approvals are limited to 14 days, with specific clinical criteria required for continuation.
Action Required
By July 1, 2001: Pharmacy and billing teams must implement new prior authorization workflow for somatropin claims. (1) Update pharmacy system to flag all somatropin [(rDNA origin) for injection] prescriptions for prior authorization through First Health Services at (877) 888-2939 before dispensing. (2) Establish process to verify patient meets all clinical criteria: AIDS diagnosis + active anti-viral therapy + HIV-associated wasting with documented weight loss or BCM measurements via BIA test. (3) Configure billing system to expect error code 537 postings for dosage violations and route to First Health for resolution. (4) Train pharmacy staff on authorization limits: initial 14-day supply, then 10 additional weeks if criteria met, then 28-day intervals for continued therapy with documented positive response (≥2% weight/BCM increase). (5) Implement re-treatment authorization process for three 4-week courses after therapy lapses. (6) Apply existing 75% early refill rule to all somatropin claims. Claims submitted without prior authorization will be denied by the POS system.