New Jersey State Upper Limit (SUL)

Phil Murphy, Governor

Frequently Asked Questions

What is a State Upper Limit (SUL) pricing methodology?
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.

What are the different payment methodologies for the New Jersey Medicaid program?
The New Jersey Division of Medical Assistance and Health Services (DMAHS) reimbursement formula is the lowest of  Wholesale Acquisition Cost (WAC) - 1%, the pharmacy’s usual and customary charge, the FUL, or the SUL.

How frequently will the SUL rate schedule be updated?
The SUL list will be updated quarterly.

What if I have a question or an issue with the reimbursement for a prescription on the SUL list?
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, fax 1-877-350-2808, or email via our website contact page. Voicemail is available after hours and on State recognized holidays; messages will be returned promptly during the next business day.

Where can I find updated SUL lists and proposed SUL changes?
Current SUL lists, previous SUL lists, and proposed changes to the SUL list can be found at www.njsul.com.