MedicaidCoverageMedium impact
BT202110: IHCP clarifies drugs carved-out of managed care and PA criteria
Indiana Medicaid (IHCP)·IN · Oncology, Hematology, Pulmonology +3 more·Managed Care
Effective date
Jan 1, 2021
We identified it
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.
Action Required
Immediately: Billing 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. Update billing system to use correct HCPCS codes for CAR-T treatments: Q2042 for Kymriah, C9073 for Tecartus, Q2041 for Yescarta. Verify prior authorization requirements are obtained from appropriate FFS entities before treatment.