Summary
New Jersey Medicaid and related programs (PAAD, GAP, CFDP, GSHP, ADDP) are removing 7 pharmaceutical drugs from Federal Medicaid Upper Limits (MAC) reimbursement due to recent price changes. Effective December, these drugs will be reimbursed at the lower of average wholesale price minus applicable discounts plus dispensing fee, or usual and customary charge. Pharmacy providers may submit claim adjustment requests for affected claims with service dates on or after December using form FD MMIS.
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What to do
Action · 4 steps
01Before December effective date: Billing team must update pharmacy billing system to remove MAC reimbursement pricing for the following 7 drugs and apply AWP-minus-regression discount pricing instead: Acetaminophen/Hydrocodone Bitartrate (Anexia), Methylprednisolone (Medrol), Prazepam (Centrax), Prednisolone Acetate (PredForte), Prednisolone Sodium Phosphate (Inflabase Forte/Mild), and Trifluoperazine Hydrochloride (Stelazine).
02Pharmacy providers must be notified of the pricing change.
03For pharmacy claims with dates of service on or after December that were incorrectly processed under MAC limits, submit claim adjustment requests on form FD MMIS per Fiscal Agent Billing Supplement instructions.
04Retain this newsletter numerically behind the newsletter tab for future reference.
Original notice
Newsletter Vol. 3, No. 05
njmmis.com · Always check the source before changing claims.
Related changes
See all New Jersey Medicaid changes →Newsletter Vol. 2, No. 10MediumNo effective date · Provider NoticeNewsletter Vol. 3, No. 01MediumNo effective date · Provider NoticeNewsletter Vol. 3, No. 02MediumNo effective date · Medical PolicyNewsletter Vol. 3, No. 03LowNo effective date · Provider NoticeBrowse every New Jersey Medicaid change in the policy list