MedicaidPrior AuthMedium impact
Newsletter Vol. 7, No. 29
New Jersey Medicaid·NJ · Pharmacy·Prior Authorization
Effective date
Jun 1, 1997
We identified it
Jun 20, 2026
Summary
This policy exempts Medicaid HMO beneficiaries from the 'Brand Medically Necessary' handwritten requirement for Maximum Allowable Cost (MAC) prescriptions. The requirement remains in effect for all Fee-for-Service (FFS) Medicaid beneficiaries. This change eliminates a prior authorization/documentation burden for HMO-enrolled patients only.
Action Required
Immediately: Pharmacy and billing teams must update MAC dispensing workflows to distinguish between Medicaid HMO and FFS beneficiaries. For HMO members, stop requiring the handwritten 'Brand Medically Necessary' statement on prescriptions for MAC drugs. For FFS members, continue enforcing the handwritten requirement exactly as stated (no check-off boxes, initials, or preprinted statements). Update pharmacy systems and staff training to reflect this distinction. Verify that individual HMOs have not implemented their own MAC requirements that supersede this change. Failure to apply the correct requirement by plan type may result in claim denials or improper reimbursement.