Maryland Medicaid: New State-Mandated Updates to Specialty Pharmacy Prior Authorization
Effective December 1, 2024, UnitedHealthcare Community Plan (Medicaid) members in Maryland will be required to obtain prior authorization for certain specialty medications. This new requirement aims to ensure that members receive the most appropriate and effective treatments while managing healthcare costs.
Drug name | HCPCS code (s) |
Abecma® (idecabtagene vicleucel) | Q2055 |
Acthar® Gel (repository corticotropin injection) | J0801 |
Adzynma™ (ADAMTS13, recombinant-krhn) | J7171 |
Amondys 45® (casimersen) | J1426 |
Breyanzi® (lisocabtagene maraleucel) | Q2054 |
Carvykti™ (ciltacabtagene autoleucel) | Q2056 |
Cortrophin® Gel (repository corticotropin injection) | J0802 |
Cosentyx® IV (secukinumab) | J3247 |
Elevidys™ (delandistrogene moxeparvovec-rokl) | J1413 |
Elfabrio® (pegunigalsidase alfa-iwxj) | J2508 |
Evkeeza® (evinacumab-dgnb) | J1305 |
Eylea® HD (aflibercept) | J0177 |
Hemgenix™ (etranacogene dezaparvovec-drlb) | J1411 |
Lamzede® (velmanase alfa-tycv) | J0217 |
Omvoh™ (mirikizumab-mrkz) | J2267 |
Pombiliti™ (cipaglucosidase alfa-atga) | J1203 |
Qalsody™ (tofersen) | J1304 |
Roctavian™ (valoctogcogene roxaparvovec-rvox) | J1412 |
Rystiggo™ (rozanolixizumab-noli) | J9333 |
Tecartus® (brexucabtagene autoleucel) | Q2053 |
Veopoz™ (pozelimab-bbfg) | J9376 |
Vyjuvek™ (beremagene geperpavec-svdt) | J3401 |
Vyvgart® (efgartigimod alfa-fcab) | J9332 |
Vyvgart® Hytrulo™ (efgartigimd alfa and hyaluronidase-qvfc) | J9334 |
Zynteglo™ (betibeglogene autotemcel) | J3393 |
How to Submit a Request: You can submit a prior authorization request through the UnitedHealthcare Provider Portal:
- Visit UHCprovider.com and click “Sign In” at the top-right corner.
- Enter your One Healthcare ID and password.
- If you’re a new user without a One Healthcare ID, go to UHCprovider.com/access to create one.
- From the menu, select “Prior Authorizations.”
- Scroll down to “Create a new notification or prior authorization request” and click “Create New Submissions.”
- Fill in the necessary details and submit your request.
Please Note: For the following cell and gene therapies, contact Optum Transplant Services at 888-805-1802 to submit your prior authorization request:
- Abecma
- Breyanzi
- Carvykti
- Tecartus
- Zynteglo
Services provided without prior authorization request made before the service date will not be paid for. In such circumstances, the provider will be banned from balance billing members; thus, the cost of the medication cannot be shifted to the patient. This policy is used to save the patients from any shock of being asked to contribute some amount of money and also to ensure that the insurance company complies with the set standards.
Providers are encouraged to submit prior authorization requests as early as possible about the planned service date to enable adequate time for processing the request. The following guidelines are important to follow so that the provider can guarantee that the patients get the right treatments without gaps or costs.