MedicaidPrior AuthMedium impact
Newsletter Vol. 11, No. 20
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Mar 1, 2001
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid and related programs (PAAD, CF, ADDP) are implementing revised Prospective Drug Utilization Review (PDUR) standards effective March 1, 2001. Changes include: RespiGam coverage limited to children under 2 years, therapeutic duplication exemptions for multiple strengths of same drug when prescribed by same physician, warfarin-barbiturate interaction exemption when from same physician, Baycol maximum daily dosage capped at 0.8mg, and niacin-statin combination exemption from duplication monitoring. Claims exceeding these thresholds will be denied with error codes requiring prior authorization through First Health Services.
Action Required
By March 1, 2001: Billing and pharmacy teams must implement the following monitoring updates in the POS claims processing system: (1) Configure RespiGam claims to deny with Error Codes 535/423 for beneficiaries age 2 and older, requiring pharmacist to contact First Health Services for prior auth. (2) Update therapeutic duplication rules to exempt multiple strengths of same drug when prescribed by same physician (requires accurate prescriber service numbers in claims); deny with Error Codes 405/423 when prescribed by different physicians. (3) Create exemption for warfarin and barbiturate combinations from same physician; deny with Error Codes 877/423 when from different physicians. (4) Set Baycol maximum daily dosage limit to 0.8mg and deny with Error Codes 535/423 when exceeded. (5) Exempt niacin and HMG-CoA Reductase Inhibitor combinations from therapeutic duplication monitoring regardless of prescriber. Pharmacists must be trained to recognize error codes and contact First Health Services (877-266-3589) for required prior authorizations. Verify prescriber service numbers (PSNs) are accurately reported on all claims to ensure proper system processing. Failure to implement will result in inappropriate claim denials and delays in pharmacy services.