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Indiana Medicaid (IHCP)Medicaid · Coverage · Managed Care · IN · Oncology, Hematology, Pulmonology +3 moreMedium impact

BT202110: IHCP clarifies drugs carved-out of managed care and PA criteria

Act
immediately
Effective date
Jan 1, 2021
Identified
Jun 19, 2026

Summary

IHCP clarifies that 8 classes of high-cost specialty drugs (including CAR-T therapies, gene therapies, cystic fibrosis agents, and others) are carved out of managed care and processed through fee-for-service, with specific prior authorization criteria and billing codes for CAR-T treatments.

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What to do

immediately · 3 steps
01Billing team must ensure all claims for the 8 carved-out drug classes (CAR-T therapies, gene therapies, cystic fibrosis agents, hemophilia factors, hepatitis C agents, muscular dystrophy agents, sickle cell agents, and SMA agents) are submitted to fee-for-service (OptumRx for pharmacy, Gainwell Technologies for medical) rather than managed care plans.
02Update billing system to use correct HCPCS codes for CAR-T treatments: Q2042 for Kymriah, C9073 for Tecartus, Q2041 for Yescarta.
03Verify prior authorization requirements are obtained from appropriate FFS entities before treatment.

Codes mentioned

Q2042C9073Q2041

Original notice

BT202110: IHCP clarifies drugs carved-out of managed care and PA criteria
in.gov · Always check the source before changing claims.
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Related changes

See all Indiana Medicaid (IHCP) changes →
BT202551: IHCP updates PA criteria for CAR-T therapiesMediumEffective Jun 26, 2024 · Provider BulletinBT202109: Coverage and billing information for the 2021 annual HCPCS codes updateMediumEffective Jan 1, 2021 · Claims & BillingBT202128: Coverage and billing information for the April 2021 HCPCS codes updateMediumEffective Apr 1, 2021 · Claims & BillingBT202158: IHCP updates Outpatient Fee ScheduleMediumNo effective date · Claims & BillingBrowse every Indiana Medicaid (IHCP) change in the policy list

Related policy hubs

Indiana Medicaid (IHCP) policiesIN policy changesOncologyHematologyPulmonologyNeurologyOphthalmologyInfectious DiseaseCode Q2042Code C9073Code Q2041

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