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New Jersey MedicaidMedicaid · Reimbursement · Provider Notice · NJ · PharmacyMedium impact

Newsletter Vol. 3, No. 32

Act
immediately
Effective date
Aug 1, 2024
Identified
Jun 20, 2026

Summary

New Jersey Medicaid and related programs (PAAD, GAP, CFDP, GSHP, ADDP) are removing Federal Medicaid Upper Limits (MAC) pricing for seven specific drugs due to recent pharmaceutical market price changes. Reimbursement for these drugs will now be based on the lower of Average Wholesale Price (AWP) minus applicable discounts plus dispensing fee, or Usual and Customary Charge.

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What to do

immediately · 4 steps
01Billing team must update pharmacy claims processing for New Jersey Medicaid, PAAD, GAP, CFDP, GSHP, and ADDP programs.
02Remove MAC pricing edits for the following drugs: Amiloride Hydrochloride (Midamor), Butabarbital Sodium (Butisol Sodium), Chloramphenicol (Chloromycetin), Dexchlorpheniramine Maleate (Polaramine), Potassium Chloride (extended-release capsule), and Sulfacetamide Sodium (Sulamyd Sodium).
03Configure billing system to calculate reimbursement using AWP minus regression discounts (if applicable) plus dispensing fee, or Usual and Customary Charge, whichever is lower.
04Verify that pharmacy software reflects the new reimbursement methodology for these NDCs.
If missed: Failure to update pricing rules will result in claim denials or incorrect reimbursement.

Original notice

Newsletter Vol. 3, No. 32
njmmis.com · Always check the source before changing claims.
View original ↗

Related changes

See all New Jersey Medicaid changes →
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