Marylandphysicianscarempc Prior Authorization Lookup
Latest Marylandphysicianscarempc prior authorization updates14
- Prior AuthClinical/Medical PolicyEff. 2024-01-01Gender-Affirming Care Prior Authorization and Coverage CriteriaDefines Maryland Physicians Care coverage, required documentation, and prior authorization requirements for gender-affirming medical treatments, fertility preservation, and surgeries for members when criteria are met.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyEff. 2023-04-01Infusion and Injection Services Administered in Unregulated Space (Site of Service - Outpatient)Defines Maryland Physicians Care requirements for site-of-care determination and prior authorization for outpatient infusion and injection services for Maryland Medicaid members, applying to participating and non-participating providers and infusion/home infusion service providers.All marylandphysicianscarempc updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-03-01NIA Prior Authorization for Outpatient Rehabilitative and Habilitative Physical Medicine Services (including chiropractor-provided physical therapy)NIA will manage utilization review and prior authorization for outpatient rehabilitative and habilitative physical medicine services (including certain chiropractic physical therapy) for Maryland Physicians Care members aged 21 and older, and describes how to request authorizations.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyEff. 2018-10-05Interventional Pain Management (IPM) prior authorization programGoverns prior authorization requirements and administrative processes for non-emergent outpatient interventional pain management procedures for Maryland Physicians Care members; affects ordering and rendering providers who perform specified IPM procedures.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyActemra (tocilizumab) IV prior authorizationDefines Maryland Physicians Care prior authorization requirements, renewal rules, and coverage limitations for intravenous tocilizumab (Actemra IV) across listed rheumatologic and related indications for prescribers and payers.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyAcute Hereditary Angioedema Products: Berinert, Kalbitor, and RuconestDefines prior authorization, coverage criteria, and renewal requirements for Berinert, Kalbitor, and Ruconest for treatment of acute hereditary angioedema (HAE) attacks for Maryland Physicians Care members and providers.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyAdakveo (crizanlizumab-tmca) — coverage criteria for sickle cell diseasePolicy governs prior authorization and coverage criteria for Adakveo (crizanlizumab-tmca) to reduce vaso-occlusive crises in patients with sickle cell disease aged 16 and older for members of Maryland Physicians Care.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyAdzynma (ADAMTS13, recombinant-krhn) prior authorizationDefines prior authorization, coverage criteria, dosing, and renewal rules for Adzynma for prophylactic or on‑demand enzyme replacement therapy in pediatric and adult patients with congenital thrombotic thrombocytopenic purpura (cTTP). Applies to prior authorization requests submitted to the payer.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyAlpha1-Proteinase Inhibitors (Human): Aralast NP, Glassia, Prolastin-C, ZemairaDefines prior authorization, coverage criteria, and renewal requirements for human alpha1-proteinase inhibitor products (Aralast NP, Glassia, Prolastin-C, Zemaira) for treatment of congenital alpha1-antitrypsin deficiency with emphysema for Maryland Physicians Care members and prescribers.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyAltuviiio (antihemophilic factor [recombinant]) prior authorizationDefines prior authorization, renewal, and coverage limitations for Altuviiio (intravenous antihemophilic factor recombinant) for members with hemophilia A; applies to providers submitting PA requests to Maryland Physicians Care.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyExon‑skipping and gene therapy drugs for Duchenne muscular dystrophy (Amondys 45, Elevidys, Exondys 51, Vyondys 53, Viltepso)Prior authorization policy defining coverage criteria, initial and reauthorization requirements, and coding for casimersen, delandistrogene moxeparvovec, eteplirsen, golodirsen, and viltolarsen for treatment of Duchenne muscular dystrophy (DMD). Applies to prescribers and members seeking payer coverage under this Maryland Physicians Care policy.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyHIV Pre-Exposure Prophylaxis (PrEP) — Apretude and YeztugoDefines prior authorization requirements for coverage of Apretude (cabotegravir injectable) and Yeztugo (lenacapavir) for HIV pre-exposure prophylaxis (PrEP) in eligible adults and adolescents weighing ≥35 kg, including initial and reauthorization criteria and required documentation for prescribers.All marylandphysicianscarempc updates
- Prior AuthClinical/Medical PolicyHIV medication coverage and prior authorization FAQThis document explains Maryland Physicians Care (MPC) coverage policies, preferred agents, prior authorization processes, copays, pediatric exceptions, and emergency fill allowances for HIV-related medications for MPC members.All marylandphysicianscarempc updates
- Prior AuthReimbursement/Payment PolicyUtilization Review Matrix — CPT imaging code management (professional claims)Matrix governing how NIA (on behalf of Maryland Physicians Care) manages utilization review and claim adjudication for specified professional CPT-4 procedure codes (primarily imaging). It affects claims processing and prior authorization/management of those CPT codes when submitted on professional (HCFA 1500) claims.All marylandphysicianscarempc updates
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Tool Description
Search Marylandphysicianscarempcprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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