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Iowa MedicaidMedicaid · Administrative · Pharmacy · IA · PharmacyHigh impact

IL 2742-MC-FFS: Pharmacy Benefit Carve-Out

Effective date
Dec 1, 2026
Identified
Oct 17, 2026

Summary

Effective December 1, 2026, Iowa Medicaid is transitioning outpatient pharmacy benefits for managed care members from MCO administration to fee-for-service administration through Optum Rx. All outpatient pharmacy claims with dates of service on or after December 1, 2026, must be submitted using new point-of-sale information (BIN: 011933, PCN: IAPOP) and will be processed by Optum Rx instead of MCOs. Prior authorizations will also be administered by Optum Rx beginning December 1, 2026.

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What to do

Action · 6 steps
01Before December 1, 2026: Billing team, pharmacy staff, and prescribing providers must update internal systems and workflows to submit all outpatient pharmacy claims using the new point-of-sale billing information (BIN: 011933, PCN: IAPOP, ID: Member's Medicaid ID#).
02MCO pharmacy prior authorization departments will accept PA requests only until 4:00pm CT on Monday, November 30, 2026; PAs received after that time must be submitted to Optum Rx on or after December 1, 2026.
03Ensure billing staff are aware that pharmacy claims with dates of service prior to December 1, 2026, will continue to be processed by MCOs, while all claims on or after December 1, 2026, must route to Optum Rx.
04Review the preferred drug list and prior authorization requirements before implementation.
05Direct post-transition inquiries to Optum Rx (POS Helpdesk: 1-877-463-7671 or 515-256-4608; PA Helpdesk: 1-877-776-1567 or 515-256-4607).
06Note that physician-administered medications and durable medical equipment remain under MCO medical benefits and are not affected by this carve-out.

Original notice

IL 2742-MC-FFS: Pharmacy Benefit Carve-Out
secureapp.dhs.state.ia.us · Always check the source before changing claims.
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