Medical Drug Benefit (J Code)

Effective through 12/31/2022: A prior authorization must be obtained from Magellan Rx before Medicaid medical pharmacy (J-code) services are provided by practitioners in physician offices, outpatient facilities, and home infusion centers for the prior authorized Healthcare Common Procedure Coding System (HCPCS) codes for all UPHP Medicaid lines of business. Requests can be made via the Magellan Rx portal or by calling 800-424-8241. Retrospective requests will not be reviewed. Magellan Rx offers peer-to-peer discussions for providers prior to any adverse determination. Utilize this process to provide information for evaluation of a request.

As of 1/1/2023, all applicable Medicaid Medical Pharmacy (J Code) prior authorization requests will now be processed directly by UPHP.  Please utilize the fax request form linked below for all new requests to 906-225-4516.  UPHP policy does not allow for retro-authorization (back dating) of requests.  Please utilize drug specific criteria (effective 1/1/2023) below for your review.  Medicare Part B drugs do not require prior authorization.

*Please note that if the ancillary/service provider is not in the UPHP provider network and there is not current out-of-network authorization, this request will be denied. To verify if a provider is in the UPHP network, please review the website at www.uphp.com.  To verify if an out-of-network authorization is current please call UPHP Customer Service at: 800-835-2556.

• Access to MagellanRx Medical Pharmacy Portal
• UPHP Medical Pharmacy Request Form
• Medical Pharmacy Drugs that will require a Prior Authorization for Medicaid as of 1/1/2023
• UPHP Medical Pharmacy Drug Criteria
  • UPHP Med Pharmacy PA Criteria J3357 Stelara SQ
  • UPHP Med Pharmacy PA Criteria J0172 Aduhelm 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes IVIG 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes Infliximab 
  • UPHP Med Pharmacy PA Criteria J2323 Tysabri 
  • UPHP Med Pharmacy PA Criteria J0129 Orencia 
  • UPHP Med Pharmacy PA Criteria J0585 Botox 
  • UPHP Med Pharmacy PA Criteria Multiple J Codes SCIG
  • UPHP Med Pharmacy PA Criteria J0586 Dysport
  • UPHP Med Pharmacy PA Criteria J2357 Xolair
  • UPHP Med Pharmacy PA Criteria Multiple J Codes Pegfilgrastim
  • UPHP Med Pharmacy PA Criteria J3380 Entyvio
  • UPHP Med Pharmacy PA Criteria J2507 Krystexxa
  • UPHP Med Pharmacy PA Criteria J2350 Ocrevus