Newsletter Vol. 3, No. 66

REQUIREMENTS: - All pharmacy providers participating in NJ Medicaid and PAAD programs must complete and submit Form FD (Pharmacy Provider Certification Statement) annually to Unisys, CN, Trenton, NJ (Attn: Form FD) - Billing/Operations team must ensure ALL sections of Form FD are completed with no missing information, or the form will be returned for corrections - Attach a copy of the pharmacy's valid pharmacy permit to the submitted Form FD - If seeking optional increments to basic dispensing fee, providers must include information on: hours of emergency service, patient consultation, and impact allowance (Form FD Section II) - Pharmacy providers in business less than one year must have prescription volume projected for the entire year to determine regression category - High-volume providers (prescription volume at or above threshold) may elect to opt out of volume reporting on Form FD but must still complete all remaining sections and return with valid pharmacy permit - DEADLINE: Form must be received by Unisys before changes become effective - CONSEQUENCES OF INACTION: Failure to submit properly completed Form FD will automatically place pharmacy in maximum regression discount category and basic dispensing fee category without qualifying for fee increments. Changes cannot become effective until properly completed form is received by Unisys.