News and Events

Coronavirus Information for Providers
Important Claims Processing Update
Training Opportunities for Providers
Healthy Babies – Pregnancy and Postpartum Coverage (7/1/23)

MPRA Requirements (PDF)
Monkeypox Update to Maryland HealthChoice Program (6/23/22)
Ambulatory Surgery Center Requirements for Pain Management and Orthopedic Surgery Services
Maryland Statewide Human Monkeypox (MPX) Vaccination Pre-Registration System
JHH Transplant Program Letter

New Opioid Prior Authorization Requirement – 90 MME Limit (PDF)
Opioid Overdose Clinical Tools
Opioid Prescription Checklist (PDF)
Guidelines for Prescribing Opioids (PDF)
Non-Opioid Treatments (PDF)

Maryland’s Department of Health (the Department) instituted a risk mitigation policy, effective January 1, 2021, to protect the HealthChoice program from utilization fluctuations related to very high-cost drugs. The policy covered both Physician Administered Drugs and retail pharmacy drugs that have an expected annual cost of over $400,000. For CY 2024, the policy has been updated to include drugs with an annual cost of over $500,000. The specific drugs are found here. The list of drugs is subject to change during the year if a new drug receives FDA approval and is a covered Medicaid benefit with an expected annual cost of over $500,000.

PLEASE NOTE THAT PRIOR AUTHORIZATION IS REQUIRED FOR THESE VERY HIGH-COST DRUGS REGARDLESS OF PLACE OF SERVICE.

THIS MEANS THAT EVEN IF YOU HAVE AN AUTHORIZATION FOR INPATIENT ADMISSION OR HOSPITAL OUTPATIENT SERVICES, ANY DRUG ON THIS LIST WILL REQUIRE A SPECIFIC AUTHORIZATION FOR THAT MEDICATION PRIOR TO ADMINISTRATION.

List of High-Volume Drugs Requiring Prior Authorization

4th Quarter 2023 (PDF)
1st Quarter 2024 (PDF)
2nd Quarter 2024 (PDF)
3rd Quarter 2024 (PDF)