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MedicaidReimbursementMedium impact

Newsletter Vol. 3, No. 13

New Jersey Medicaid·NJ · Pharmacy·Provider Notice
Effective date
Not stated
We identified it
Jun 20, 2026
Days to comply
—

Summary

Effective immediately, specific pharmaceutical products are no longer subject to Federal Medicaid Upper Limits (MAC) pricing due to recent marketplace price changes. Billing teams must remove MAC pricing restrictions for the listed drugs (Cafergot, Norpramin, Placidyl, Cortisporin, Butazolidin, Metimyd, and Gantanol) and revert to standard reimbursement processing without MAC price caps.

Action Required

Action needed
Immediately: Pharmacy billing team must update billing system to remove Federal Medicaid Upper Limits (MAC) pricing restrictions for the following drugs: Cafergot (Caffeine/Ergotamine Tartrate), Norpramin (Desipramine Hydrochloride), Placidyl (Ethchlorvynol), Cortisporin (Hydrocortisone/Neomycin Sulfate/Polymixin B Sulfate - all ophthalmic and otic formulations), Butazolidin (Phenylbutazone), Metimyd (Prednisolone Acetate/Sulfacetamide Sodium), and Gantanol (Sulfamethoxazole). Remove claim rejection rules tied to MAC limits for these specific medications. Verify pharmacy management software reflects changes to prevent claim denials. Failure to update pricing logic will result in claim denials when pharmacies bill above previous MAC thresholds.

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