North Carolina Medicaid: Prior authorization updates for specialty pharmacy medications
AI Summary
Starting December 1, 2025, UnitedHealthcare Community Plan in North Carolina will require prior authorization for 10 specialty gene and cell therapy medications. Some therapies require contacting Optum Transplant Services directly at 888-805-1802 instead of using the standard portal.
Action Required
Before December 1, 2025: Update billing system to require prior authorization for the 10 listed specialty gene/cell therapy HCPCS codes. Train staff that Casgevy, Lenmeldy, Lyfgenia, Skysona, and Zynteglo require calling Optum Transplant Services at 888-805-1802 instead of using the UnitedHealthcare Provider Portal. All other therapies use standard portal submission. Prior authorization must be obtained before service date or claims will be denied and providers cannot balance bill members.
Affected Billing Codes
Plan Types
Medicaid
States
NC
Specialties
hematology, oncology, neurology, ophthalmology