Gender Affirming Care Drug Product Carve-Outs Effective 10/13/2026

Effective on 10/13/2026, for Michigan Medicaid managed care plans, drug classes that have the potential to be used to provider Gender Affirming Care (GAC) are carved out from the managed care Medicaid pharmacy benefit. This means that pharmacy claims billed to managed care plans will reject with NCPDP Reject Code 831 and indicate a message to bill the claim to fee-for-service pharmacy benefit manager (PBM) PrimeTherapeutics, the State of Michigan Medicaid Program's pharmacy benefit claims processor. 

New drug classes that are being carved out include medications that may be used, but are not necessarily always used, to provide gender affirming care (GAC) services including treatment for gender dysphoria, and gender transition. These drug classes are being carved out regardless of the indication/diagnosis that the drug is being used to treat for an individual patient. Please refer to the table at the end of this announcement for the new carved out drug classes and examples of commonly utilized medications within those classes. 

The State of Michigan Medicaid Program & Michigan Department of Health & Human Services (MDHHS) has mandated that all Michigan Medicaid managed care plans, including Meridian Health Plan of Michigan, conduct this change in order remain in compliance with a federal regulation called the CMS-2451-F final rule. For more information on the CMS-2451-F final rule, “Prohibition on Federal Medicaid and CIP Funding for Sex Rejecting Procedures Furnished to Children and Youth.” 

The State of Michigan Medicaid Program will continue to cover these treatments according to Michigan Medicaid fee-for-service pharmacy rules and restrictions using state general funds. 

For Michigan Meridian Medicaid members, at the pharmacy point of sale, all carve out drug class pharmacy claims will reject with Reject Code 831 = Product Service ID Carve-Out, Bill Medicaid Fee For Service PBM Prime Therapeutics, call phone #877-624-5204.

The State of Michigan Medicaid fee-for-service pharmacy benefit manager PrimeTherapeutics will be responsible for pharmacy claims processing and adjudication of these medications which are carved out on and after 10/13/2026.  All pharmacy carve out claims should be submitted to the MI Medicaid fee-for-service pharmacy benefit manager PrimeTherapeutics with the following billing information:

• PrimeTherapeutics BIN: 009737
• PrimeTherapeutics PCN: P008009737
• PrimeTherapeutics Group: MIMEDICAID
• PrimeTherapeutics ID number: (member’s unique 10-digit Medicaid ID)

Several different classes of medications are already carved out from the managed care health plan pharmacy benefits for MI Medicaid members, including many psychotropic medications, rare disease medications, and drugs to treat HIV.  Since most pharmacies are familiar with the reject messaging and claims processing routine for existing MI Medicaid pharmacy carve-outs, the health plan anticipates minimal disruption to members, minimal rise in call center inquiries, and minimal rise in prior authorization volume. However, since these are new drug classes including some highly utilized drug products, pharmacy teams and call centers should be aware that this is a planned change. Any override requests from members, prescribers, or pharmacies for carve out medications need to be directed to the PrimeTherapeutics pharmacy help desk by calling 877-624-5204.

The MI Medicaid fee-for-service pharmacy benefit will conduct a 90-day transition supply coverage for all MI Medicaid members to allow coverage of any agents in the new HIC3 pharmacy carve-out drug classes that require prior authorization, from 10/13/2026 until 01/12/2027. Meridian Health Plan of Michigan will provide MDHHS with prior authorization data to honor existing prior authorizations for newly carved out drugs that require a PA, for those PAs that have an end date/term date on 1/13/2027 or later.