MedicaidPrior AuthHigh impact
Newsletter Vol. 11, No. 48
New Jersey Medicaid·NJ · Pharmacy, Oncology, Hematology +3 more·Provider Notice
Effective date
Jul 1, 2001
We identified it
Jun 20, 2026
Summary
New Jersey implemented Prospective Drug Utilization Review (PDUR) standards effective July 1, 2001, requiring pharmacists to notify First Health Clinical Services prior to dispensing epoetin, filgrastim, and linezolid to initiate the Medical Exception Process. Emergency dispensing of up to 6-day supplies is permitted without prior authorization. This applies to Medicaid FFS, NJ FamilyCare FFS, PAAD, CF, Senior Gold, and ADDP programs.
Action Required
By July 1, 2001: Billing and pharmacy teams must implement the following requirements: (1) Establish protocol requiring pharmacists to contact First Health Clinical Services at 1-877-888-2939 (available 24/7) prior to dispensing epoetin, filgrastim, or linezolid prescriptions to initiate Medical Exception Process; (2) Update pharmacy dispensing systems to flag these three drugs for prior authorization requirement; (3) Train pharmacy staff that emergency dispensing of up to 6-day supplies is permitted without prior authorization only; (4) Document in billing system that First Health will outreach prescribers for diagnostic information to verify appropriate diagnoses per the specified clinical criteria; (5) Ensure billing team understands approved diagnoses for each drug (epoetin: anemia with ESRD/CRD/AIDS/ARC/chemotherapy/pre-op transfusion reduction; filgrastim: bone marrow transplant, chemotherapy-induced neutropenia, chronic/congenital neutropenia, and other specified conditions; linezolid: previous hospitalization with susceptible organisms including MRSA, VRE, streptococcus species, and others). Claims for these medications without prior authorization or valid prior approval will be denied. Contact Chief Pharmaceutical Consultant at (609) 588-2724 or First Health Customer Service at 1-877-266-3589 for questions.