MedicaidPrior AuthMedium impact
Senior Services News Vol. 5, No. 3
New Jersey Medicaid·NJ · Pharmacy, Dermatology, Psychiatry·Medical Policy
Effective date
Jun 1, 2001
We identified it
Jun 20, 2026
Summary
Effective June 1, 2001, PAAD and Senior Gold programs now provide coverage for hair loss medications (e.g., finasteride/Propecia) and cosmetic drugs (e.g., eflornithine/Vaniqa) under specific medical criteria. All claims require prior authorization through the Medical Exception Process, with initial 30-day supply limits enforced at point-of-sale. Claims exceeding 30 days will be automatically denied by edit 537.
Action Required
By June 1, 2001: Billing and pharmacy teams must implement the following: (1) Ensure all PAAD and Senior Gold claims for hair loss and cosmetic medications route through the Medical Exception Process prior to dispensing; (2) Configure point-of-sale system to enforce edit 537, which limits initial fills to 30-day supplies and triggers automatic contact to First Health Services at (877) 888-2939 for authorization; (3) Train pharmacy staff to recognize covered medications (Propecia for male psychiatric-related hair loss and female hirsutism; Vaniqa for female facial hirsutism) and enforce coverage criteria; (4) Implement workflow to ensure prescribers receive medical justification requests from First Health Services based on specified criteria. Claims submitted without prior authorization or exceeding 30-day limits will be denied. Update internal protocols and staff training materials to reference Newsletter Volume 9 No. 67 (November 1999) for Medical Exception Process procedures.