MedicaidPrior AuthHigh impact
Newsletter Vol. 10, No. 34
New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
May 15, 2000
We identified it
Jun 20, 2026
Summary
New Jersey implemented enhanced Prospective Drug Utilization Review (PDUR) monitoring to enforce maximum daily dosage standards for multiple drug classes effective May-June 2000. Claims exceeding these dosage limits will trigger Error Code 535 and require prior authorization from First Health Services. This affects pharmacy claims across Medicaid, General Assistance, NJ KidCare, PAAD, CF, and ADDP programs.
Action Required
By May 15, 2000 (ACE Inhibitors, Beta-blockers, Calcium Channel Blockers, Cardiotonics, HMG CoA RI): Pharmacy billing team must implement maximum daily dosage edits in claims processing system per attached table. All claims exceeding limits will generate Error Code 535 and require prior authorization from First Health Services (877-266-3589). By May 30, 2000: Add PDUR edits for sedative-hypnotics with age-differentiated limits (note: Flurazepam, Temazepam, and Triazolam have reduced limits for patients over 65). By June 15, 2000: Implement PDUR edits for anxiolytics, gastrointestinal agents, H2 antagonists, NSAIDs, and PPIs with age-specific dosage standards (Alprazolam, Cimetidine, Metoclopramide, Naproxen Sodium, and Ranitidine have different limits for age 65+). Pharmacy staff must obtain prior authorization for all claims with dosages exceeding approved standards; claims without authorization will generate Error Code 423 and will not be paid. Update internal procedures to reference Newsletter Volume 9 No. 67 for Medical Exception Process details. Contact DMAHS Chief of Pharmaceutical Services at (609) 588-2724 or PAAD Pharmacy Consultant at (609) 588-7034 for questions.