State Upper Limit (SUL) rate schedules are based on the belief that chemically equivalent drug products in the same strength, dosage, and package size available from multiple sources should be reimbursed similarly. SULs are designed to maximize the cost-effectiveness of pharmacy services by setting reimbursement amounts for brand name and therapeutically equivalent drug products at the same price, based on the cost of the products. The SUL rate usually applies to both the brand and generic drug products unless the prescriber writes “brand medically necessary” on the prescription or prior authorization. The Centers for Medicare and Medicaid Services (CMS) uses the same rationale to establish Federal Upper Limits (FULs) for drug products. SUL rates are state Medicaid program versions of CMS FULs.
The New Jersey Division of Medical Assistance and Health Services (DMAHS) reimbursement formula is the lowest of NADAC(National Average Drug Acquisition Cost), Wholesale Acquisition Cost (WAC) – 2%, , the FUL, the SUL Or the pharmacy’s usual and customary charge.
The SUL list will be updated quarterly.
There is a dedicated Help Desk available to assist pharmacy providers with questions or concerns regarding the SUL rate schedules. Live support is available Monday through Friday, 8:00 AM through 5:00 PM (Eastern Standard Time). Providers may call 1-855-389-9502, or email smacdisputes@optum.com. Voicemail is available after hours and on State recognized holidays; messages will be returned promptly during the next business day.
Current SUL lists, previous SUL lists, and proposed changes to the SUL list can be found at www.njsul.com.