MedicaidCoverageMedium impact
Newsletter Vol. 10, No. 29
New Jersey Medicaid·NJ · Pharmacy, Family Medicine, General Practice +2 more·Medical Policy
Effective date
Apr 1, 2000
We identified it
Jun 20, 2026
Summary
New Jersey Medicaid, General Assistance, and NJ KidCare FFS programs now provide coverage for lipase inhibitors (e.g., Xenical) effective April 1, 2000, subject to strict medical necessity criteria and prior authorization requirements. All lipase inhibitor claims require Medical Exception Process authorization, with an initial 30-day supply dispensable pending physician justification, followed by 30-day or 90-day authorized supplies.
Action Required
By April 1, 2000: Billing team and pharmacists must implement prior authorization workflow for all lipase inhibitor claims (e.g., Xenical) submitted for NJ Medicaid, GA, and NJ KidCare FFS beneficiaries. (1) Update billing system to flag lipase inhibitor claims for Medical Exception Process authorization through First Health Services (1-877-888-2939). (2) Configure system to allow initial 30-day supply dispensing without prior auth via Edit 927 trigger at point-of-sale. (3) Implement outreach protocol: First Health will contact prescribing physicians during the initial 30-day period to request justification for continued use. (4) Verify patient meets coverage criteria before claim submission: BMI ≥27 kg/m² with co-morbidities (hypertension, diabetes, or dyslipidemia) OR BMI ≥30 kg/m² without co-morbidities. (5) Configure system to limit subsequent authorizations to 90-day supplies. Claims submitted without proper prior authorization after initial 30-day supply expires will be denied. Providers and pharmacists should reference Newsletter Volume 9, No. 67 (November 1999) for Medical Exception Process procedures. Contact NJ DMAHS Chief of Pharmaceutical Services at (609) 588-2724 for questions.