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CareFirst CHPMD Members: Keep your info current. Keep yourself insured. Medicaid renewals won’t be automatic this year. Check in to make sure your contact information is up to date to receive important notices on any changes to your health insurance. To update your address, phone number or email, log in to your MHC online account.  If you need assistance, call MHC at 1-855-642-8572.

CareFirst CHPMD Providers: Encourage your patients to update their information. Find out how you can help your patients renew their coverage here.

Authorization Guidelines

Summary of services that require prior authorization

 

Download a copy of the 2023 Authorization Guidelines .

On June 1, 2023, CareFirst Community Health Plan Maryland (CareFirst CHPMD) will no longer require prior authorization for Physical Therapy, Occupational Therapy and Speech Therapy outpatient services. This will allow providers to follow the treatment plan without interruption and/or delay. For more information, please contact the Provider Services Department at ProviderMD@CareFirst.com or by phone at 410-779-9359.

Obtaining prior authorization is the responsibility of the PCP or treating provider.  Members who need prior authorization should work with their provider to submit the required clinical data.

Submit the request in one of the following ways:

  • via fax to 443-552-7407 / 443-552-7408.
  • via telephone at 800-730-8543 / 410-779-9359.

Click here to download a copy of our preauthorization request forms. 

Click here to download a copy of our medical preferred drug list.


Important Information

  • The Authorization Guidelines document is not all inclusive.
  • All inpatient services require authorizations.
  • All outpatient services in the below categories and/or outpatient services and procedures by a non-par facility or non-par provider require an authorization.
  • Authorization is not a guarantee of payment.
  • All authorizations are subject to eligibility requirements and benefit plan limitations.
  • Authorizations are issued for medical services and assumes that providers submit claims with codes billable under the current Medicaid Fee Schedule contact Provider Relations with questions.
  • Verification of eligibility and/or benefit information is not a guarantee of payment.
  • Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of coverage applicable on the date services were rendered.

Pharmacy J Codes

Drug Name NDC Codes HCPCS Codes
Abecma 59572-0515-01, 59572-0515-02, 59572-0515-03 Q2055
Actimmune 75987-0111-11, 75987-0111-10 J9216
Adcetris 51144-0050-01 J9042
Altuviiio 71104-0978-01,71104-0979-01, 71104-0980-01, 71104-0981-01, 71104-0982-01, 71104-0983-01,71104-0984-01 J7199
Amondys 45 60923-0227-02 J1426
Amvuttra 71336-1003-01 J0225
Blincyto 55513-0160-01 J9039
Breyanzi 73153-0900-01 Q2054
Bylvay 74528-0040-01,74528-0120-01 J8499
Cablivi 58468-0225-01 J3590
Carvykti 57894-0111-01,57894-0111-02 Q2056
Cerezyme 58468-4663-01 J1786
Cinryze 42227-0081-05 J0598
Crysvita* 69794-0304-01,69794-0203-01,69794-0102-01 J0584
Daybue 63090-0660-01 J8499
Elahere 72903-0853-01 J9063
Elaprase 54092-0700-01 J1743
Elevidys 60923-0501-10, 60923-0502-11, 60923-0503-12, 60923-0504-13, 60923-0505-14, 60923-0506-15, 60923-0507-16, 60923-0508-17, 60923-0509-18, 60923-0510-19, 60923-0511-20, 60923-0512-21, 60923-0513-22, 60923-0514-23, 60923-0515-24, 60923-0516-25, 60923-0517-26, 60923-0518-27, 60923-0519-28, 60923-0520-29, 60923-0521-30, 60923-0522-31, 60923-0523-32, 60923-0524-33, 60923-0525-34, 60923-0526-35, 60923-0527-36, 60923-0528-37, 60923-0529-38, 60923-0530-39, 60923-0531-40, 60923-0532-41, 60923-0533-42, 60923-0534-43, 60923-0535-44, 60923-0536-45, 60923-0537-46, 60923-0538-47, 60923-0539-48, 60923-0540-49, 60923-0541-50, 60923-0542-51, 60923-0543-52, 60923-0544-53, 60923-0545-54, 60923-0546-55, 60923-0547-56, 60923-0548-57, 60923-0549-58, 60923-0550-59, 60923-0551-60, 60923-0552-61, 60923-0553-62, 60923-0554-63, 60923-0555-64, 60923-0556-65, 60923-0557-66, 60923-0558-67, 60923-0559-68, 60923-0560-69, 60923-0561-70 J3490, J3590
Elfabrio 10122-0160-02,10122-0160-05, 10122-0160-10 J3490; J3590
Empaveli 73606-0010-01 J3490, J3590, C9399
Evkeeza 61755-0010-01, 61755-0013-01 J1305
Fyarro 80803-0153-50 J9331
Gattex 68875-0101-01, 68875-0102-01, 68875-0103-01 J3490
Haegarda 63833-0828-02, 63833-0829-02 J5099
Hemgenix 00053-0099-01, 00053-0100-10, 00053-0110-11, 00053-0120-12, 00053-0130-13, 00053-0140-14, 00053-0150-15, 00053-0160-16, 00053-0170-17, 00053-0180-18, 00053-0190-19, 00053-0200-20, 00053-0210-21, 00053-0220-22, 00053-0230-23, 00053-0240-24, 00053-0250-25, 00053-0260-26, 00053-0270-27, 00053-0280-28, 00053-0290-29, 00053-0300-30, 00053-0310-31, 00053-0320-32, 00053-0330-33 , 00053-0340-34, 00053-0350-35, 00053-0360-36, 00053-0370-37, 00053-0380-38, 00053-0390-39, 00053-0400-40, 00053-0410-41, 00053-0420-42, 00053-0430-43, 00053-0440-44, 00053-0450-45, 00053-0460-46, 00053-0470-47, 00053-0480-48 J1411
Joenja 71274-0170-60 J8499
Kimmtrak 80446-0401-01 J9274
Korlym 76346-0073-01,76346-0073-02 J8499
Krystexxa 75987-0080-10 J2507
Lamzede 10122-0180-02, 10122-0180-05,10122-0180-10 J3490, J3590
Livmarli 79378-0110-01 J8499
Myalept 76431-0210-01 J3490
Nexviazyme 58468-0426-01 J0219
Novoseven 00169-7201-01 J7189
Nulibry 73129-0001-01 J3490
Onpattro 71336-1000-01 J0222
Orfadin 66658-0204-90 J8499
Orladeyo 72769-0101-01, 72769-0102-01 J8499
Oxlumo 71336-1002-01 J0224
Poteligeo 42747-0761-01 J9204
Procysbi 75987-0101-08 J8499
Ravicti 75987-0050-06 J8499
Rethymic 72359-0001-01 J3590
Revcovi 57665-0002-01 J3590, J3490
Roctavian 68135-0927-01,68135-0927-48 J3490, J3590
Ryplazim 70573-0099-01, 70573-0099-02 J2998
Skysona 73554-2111-01 J3590
Soliris 25682-0001-01 J1300
Spinraza 64406-0058-01 J2326
Takhzyro 47783-0644-01 J0593
Tecvayli 57894-0449-01,57894-0450-01 J9380
Tepezza 75987-0130-15 J3241
Ultomiris 25682-0022-01, 25682-0025-01, 25682-0028-01 J1303
Viltepso 73292-0011-01 J1427
Vyjuvek 82194-0510-02 J3590
Vimizim 68135-0100-01 J1322
Vyondys 53 60923-0465-02 J1429
Xenpozyme 58468-0050-01 J0218
Yervoy 00003-2328-22 J9228
Zolgesma 71894-0120-02, 71894-0121-03,71894-0122-03, 71894-0123-03, 71894-0124-04, 71894-0125-04, 71894-0126-04, 71894-0127-05, 71894-0128-05, 71894-0129-05, 71894-0130-06, 71894-0131-06, 71894-0132-06, 71894-0133-07,71894-0134-07, 71894-0135-07, 71894-0136-08, 71894-0137-08, 71894-0138-08, 71894-0139-09, 71894-0140-09, 71894-0141-09 J3399
Zynteglo 73554-3111-01 J3590

*Requires a total dosage of 40mg every 2 weeks to exceed $400,000 threshold.