MedicaidCoverageHigh impact
Changes to Mental Health & AIDS Carve Out Drugs for Recipients in Managed Care Organizations
Maryland Medicaid·MD · Psychiatry, Infectious Disease, Pharmacy·Managed Care Organizations
Effective date
Jan 1, 2001
We identified it
Jun 20, 2026
Summary
Maryland Medicaid managed care organizations must now cover specific mental health and HIV/AIDS drugs on their formularies, while other mental health medications will be paid fee-for-service by the state program. MCOs are responsible for covering 13 specific drugs including anticonvulsants, sedatives, and hormone therapies, plus new HIV protease inhibitors and reverse transcriptase inhibitors.
Action Required
By January 1, 2001: Billing team must update systems to bill MCOs directly for 13 specific drugs (carbamazepine, gabapentin, lamotrigine, topiramate, midazolam, droperidol, leuprolide, clonidine, guanfacine, naltrexone, medroxyprogesterone, liothyronine, disulfiram) and HIV drugs (protease inhibitors, reverse transcriptase inhibitors). For all other mental health drug classes, bill Maryland Medicaid fee-for-service. Leuprolide and medroxyprogesterone require preauthorization when used for behavioral problems in males only. Update pharmacy billing systems to route claims to appropriate payor based on drug and prescriber type.