[47 Pa.B. 5303]
[Saturday, September 2, 2017]
[Continued from previous Web Page]
Year Code Citation(s) Subject Date Issued Bulletin Number Ch. 1121 Prior Authorization and Quantity Limits of Botulinum Toxins Pharmacy Services 12/11/09 01-09-61
09-09-62
27-09-53
02-09-52
11-09-52
30-09-52
03-09-52
14-09-52
31-09-63
08-09-61
24-09-58
32-09-52Ch. 1121 Preferred Drug List (PDL) New Drugs To Market Handbook Pages Pharmacy Services 12/11/09 01-09-60
09-09-61
27-09-52
02-09-51
11-09-51
30-09-51
03-09-51
14-09-51
31-09-62
08-09-60
24-09-57
32-09-51— Prone Restraints in Children's Facilities 12/19/09 3800-09-02 — Strategies and Practices to Eliminate The Use of Unnecessary Restraints 12/19/09 3800-09-01 Ch. 1101
1150
1241Hiberix®, Haemophilus Influenzae Type b (Hib) Vaccine 12/31/09 01-09-62
08-09-61
09-09-62
31-09-64
33-09-072010 — Special Pharmaceutical Benefits Program (SPBP)—Implementation of the Revised HIV/AIDS Formulary for SP1 Cardholders 01/25/10 08-10-02
09-10-02
24-10-02
31-10-02Ch. 1121 List of Drugs With Established Quantity Limits/Daily Dose Limits—Pharmacy Services 01/29/10 01-10-01
09-10-01
27-10-01
02-10-01
11-10-01
30-10-01
03-10-01
14-10-01
31-10-01
08-10-01
24-10-01
32-10-01Ch. 1121 Prior Authorization of Erythropoiesis Stimulating Proteins—Pharmacy Services 01/29/10 01-10-03
09-10-04
27-10-02
02-10-01
11-10-01
30-10-01
03-10-01
14-10-01
31-10-01
08-10-01
24-10-01
32-10-01Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 02/05/10 01-10-05
09-10-06
27-10-04
02-10-04
11-10-04
30-10-04
03-10-04
14-10-04
31-10-07
08-10-06
24-10-05
32-10-04Ch. 1150 Health Care Benefit Package 12 Updated Employability Assessment Procedure Code List 2-5-10 01-10-02
08-10-03
09-10-03
18-10-01
28-10-01
29-10-01
31-10-03Ch. 1147 Medical Assistance Program Outpatient Fee Schedule Procedure Code Changes for Vision Services 02/15/10 18-10-02
31-10-05
Ch. 1150 Medical Assistance Program Fee Schedule Revisions 02/19/10 99-10-01 Ch. 1101
1150
12412010 Recommended Childhood and Adolescent Immunization Schedules 03/15/10 01-10-06
08-10-07
09-10-07
31-10-09
33-10-01Ch. 1141
1144
Ch. 1121Application of Topical Fluoride Varnish by Physicians and CRNPs Prior Authorization of Neulasta—Pharmacy Services 03/15/10
04/01/1009-10-08
31-10-08
01-10-07
09-10-09
27-10-05
02-10-05
11-10-05
30-10-05
03-10-05
14-10-05
31-10-10
08-10-08
24-10-06
32-10-05Ch. 1121 Oral Buprenorphine Agents Updated Handbook Pages—Pharmacy Services 04/03/10 01-10-04
09-10-05
27-10-03
02-10-03
11-10-03
30-10-03
03-10-03
14-10-03
31-10-06
08-10-05
24-10-04
32-10-03— Implementation of New Physical Health Managed Care Organizations in the HealthChoices Southeast and Lehigh/Capital Zones 04/23/10 99-10-02 Ch. 1121 Analgesics, Narcotic Long Acting Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/01/10 01-10-15
09-10-17
27-10-12
02-10-12
11-10-12
30-10-12
03-10-13
14-10-12
31-10-18
08-10-16
24-10-13
32-10-12Ch. 1121 Fibromyalgia Agents Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/03/10 01-10-10
09-10-12
27-10-08
02-10-08
11-10-08
30-10-08
03-10-08
14-10-08
31-10-13
08-10-11
24-10-09
32-10-08Ch. 1121 Spring 2010 Preferred Drug List (PDL) Quantity Limits Update—Pharmacy Services 05/03/10 01-10-08
09-10-10
27-10-06
02-10-06
11-10-06
30-10-06
03-10-06
14-10-06
31-10-11
08-10-09
24-10-07
32-10-06Ch. 1121 Oral Immunosuppressive Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/03/10 01-10-12
09-10-14
27-10-10
02-10-10
11-10-10
30-10-10
03-10-10
14-10-10
31-10-15
08-10-13
24-10-11
32-10-10— Limitation on Allowable Other Medical Expenses Related to Nursing Facility Services 05/03/10 03-10-02 Ch. 1121 Multiple Sclerosis Agents Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/03/10 01-10-13
09-10-15
27-10-11
02-10-11
11-10-11
30-10-11
03-10-11
14-10-11
31-10-16
08-10-14
24-10-12
32-10-11Ch. 1121 Hepatitis C Agents Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/03/10 01-10-11
09-10-13
27-10-09
02-10-09
11-10-09
30-10-09
03-10-09
14-10-09
31-10-14
08-10-12
24-10-10
32-10-09Ch. 1121 Antidepressants, Other Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/03/10 01-10-09
09-10-11
27-10-07
02-10-07
11-10-07
30-10-07
03-10-07
14-10-07
31-10-12
08-10-10
24-10-08
32-10-07Ch. 1150
1121Updated Recommendations for Gardasil® Quadrivalent Human Papillomavirus (HPV) Vaccine 05/03/10 01-10-14
08-10-15
09-10-16
31-10-17
33-10-02Ch. 1121 Oral Anticonvulsants Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/21/10 01-10-18
09-10-20
27-10-15
02-10-15
11-10-15
30-10-15
03-10-16
14-10-15
31-10-21
08-10-19
24-10-16
32-10-15Ch. 1121 Angiotensin Modulator Combinations Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/21/10 01-10-17
09-10-19
27-10-14
02-10-14
11-10-14
30-10-14
03-10-15
14-10-14
31-10-20
08-10-18
24-10-15
32-10-14Ch. 1121 Pulmonary Arterial hypertension Agents, Oral and Inhaled Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/21/10 01-10-16
09-10-18
27-10-13
02-10-13
11-10-13
30-10-13
03-10-14
14-10-13
31-10-19
08-10-17
24-10-14
32-10-13Ch. 1121 Analgesics, Narcotic Short Acting Handbook Pages Pharmacy Services Spring 2010 Preferred Drug List (PDL) Update 05/21/10 01-10-19
09-10-21
27-10-16
02-10-16
11-10-16
30-10-16
03-10-17
14-10-16
31-10-22
08-10-20
24-10-17
32-10-16— Discontinued Mailing of Paper Remittance Advices 05/28/10 99-10-04 Ch. 1101
1150Announcing the Federally Mandated Change to Electronic Healthcare Transactions for Healthcare and Pharmacy Transactions 06/08/10 99-10-07 Ch. 1101
1150
1241Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 06/14/10 99-10-06 Ch. 1150 2009 HCPCS Updates and Other Procedure Code and Procedure Code/Modifier Combination Changes 06/14/10 99-10-05 Ch. 1150 Health Care Benefit Package 12 Updated Employability Assessment Procedure Code List 07/09/10 01-10-20
08-10-21
09-10-22
18-10-03
28-10-02
29-10-02
31-10-23Ch. 41 Change of Protocol for Certain Provider Appeals 07/09/10 99-10-08 Ch. 1101
1102
1121
1123
1149
1151
1163
1181
1187
1230
1243Policy Clarification Regarding Written Prescriptions—
Statement of Policy07/17/10 99-10-03
1101-10-01
1102-10-01
1121-10-01
1123-10-01
1149-10-01
1151-10-01
1163-10-01
1181-10-01
1187-10-01
1230-10-01
1243-10-01
Ch. 1121 Prior Authorization of Spiriva (Bronchodilators, Anticholinergic)—Pharmacy Services 07/29/10 01-10-21
09-10-23
27-10-17
02-10-17
11-10-17
30-10-17
03-10-18
14-10-17
31-10-25
08-10-22
24-10-18
32-10-17Ch. 1101 SelectPlan For Women—Update to Covered Services 07/30/10 01-10-22
08-10-24
09-10-21
24-10-19
28-10-03
31-10-26
33-10-03Ch. 1225 Changes to the Provision of Hemoglobin Laboratory Services by Family Planning Clinics 07/30/10 08-10-23 Ch. 1121 Electronic Prescribing for Providers That Have ePrescribing Software 08/04/10 03-10-19
09-10-25
14-10-18
18-10-04
24-10-20
27-10-18
31-10-24
33-10-04Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting—Pharmacy Services 08/27/10 01-10-26
09-10-28
27-10-21
02-10-20
11-10-20
30-10-20
03-10-22
14-10-21
31-10-29
08-10-27
24-10-23
32-10-20Ch. 1121 Prior Authorization of Analgesics, Narcotic Short Acting—Pharmacy Services 08/27/10 01-10-25
09-10-27
27-10-20
02-10-19
11-10-19
30-10-19
03-10-21
14-10-20
31-10-28
08-10-26
24-10-22
32-10-19Ch. 1121 Updated List of Drugs With Established Quantity Limits/Daily Dose Limits—Pharmacy Services 08/27/10 01-10-23
09-10-26
27-10-19
02-10-18
11-10-18
30-10-18
03-10-20
14-10-19
31-10-27
08-10-25
24-10-21
32-10-18Ch. 1101
1150
1241Updates to the Medical Assistance Program Fee Schedule for the Administration of the Vaccines Prevnar 13®, Cervarix®, Twinrix®, Recombivax HB®, and Menveo® 08/30/10 01-10-27
08-10-28
09-10-29
31-10-30
33-10-05Ch. 1150 Revisions to the Medical Assistance Program Fee Schedule Rates for Select Services 08/30/10 99/10/09 Ch. 1121
—Retrospective Drug Use Review—Pharmacy Services Specialty Pharmacy Drug Program—Updated List of Covered Drugs—Pharmacy Services 09/01/10
09/27/1099-10-10
99-10-11Ch. 1145 Recipient Access to Chiropractic Services 10/08/10 99-10-12 Ch. 1121 Antipsychotics Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-33
09-10-35
27-10-25
02-10-24
11-10-24
30-10-24
03-10-26
14-10-25
31-10-36
08-10-34
24-10-27
32-10-24Ch. 1121 Analgesics/Anesthetics, Topical Agents Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-29
09-10-31
27-10-21
02-10-20
11-10-20
30-10-20
03-10-22
14-10-21
31-10-32
08-10-30
24-10-23
32-10-20
Ch. 1121 Intranasal Rhinitis Agents Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-41
09-10-43
27-10-33
02-10-32
11-10-32
30-10-32
03-10-34
14-10-33
31-10-44
08-10-42
24-10-35
32-10-32Ch. 1121 Oral Fluoroquinolones Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-39
09-10-41
27-10-31
02-10-30
11-10-30
30-10-30
03-10-32
14-10-31
31-10-42
08-10-40
24-10-33
32-10-30Ch. 1121 Fall 2010 Preferred Drug List (PDL) and Quantity Limits Update—Pharmacy Services 11/05/10 01-10-28
09-10-30
27-10-20
02-10-19
11-10-19
30-10-19
03-10-21
14-10-20
31-10-31
08-10-29
24-10-22
32-10-19Ch. 1121 Inhaled Glucocorticoids Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-40
09-10-42
27-10-32
02-10-31
11-10-31
30-10-31
03-10-33
14-10-32
31-10-43
08-10-41
24-10-34
32-10-31Ch. 1121 Antihyperuricemics Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-31
09-10-33
27-10-23
02-10-22
11-10-22
30-10-22
03-10-24
14-10-23
31-10-34
08-10-32
24-10-25
32-10-22
Ch. 1121 Bronchodilators, Beta Agonists Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-37
09-10-39
27-10-29
02-10-28
11-10-28
30-10-28
03-10-30
14-10-29
31-10-40
08-10-38
24-10-31
32-10-28Ch. 1121 Antivirals, Oral Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-34
09-10-36
27-10-26
02-10-25
11-10-25
30-10-25
03-10-27
14-10-26
31-10-37
08-10-35
24-10-28
32-10-25Ch. 1121 Macrolides/Ketolides Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10/42
09-10-44
27-10-34
02-10-33
11-10-33
30-10-33
03-10-35
14-10-34
31-10-45
08-10-43
24-10-36
32-10-33Ch. 1121 Antibiotics, Inhaled Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-30
09-10-32
27-10-22
02-10-21
11-10-21
30-10-21
03-10-23
14-10-22
31-10-33
08-10-31
24-10-24
32-10-21Ch. 1121 Bone Resorption Suppression and Related Agents Handbook Pages—Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-30
09-10-32
27-10-22
02-10-21
11-10-21
30-10-21
03-10-23
14-10-22
31-10-33
08-10-31
24-10-24
32-10-21Ch. 1121 Bile Salts Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-35
09-10-37
27-10-27
02-10-26
11-10-26
30-10-26
03-10-28
14-10-27
31-10-38
08-10-36
24-10-29
32-10-26Ch. 1121 Antiparasitics, Topical Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-32
09-10-34
27-10-24
02-10-23
11-10-23
30-10-23
03-10-25
14-10-24
31-10-35
08-10-33
24-10-26
32-10-23Ch. 1121 Cytokine and CAM Antagonists Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/05/10 01-10-38
09-10-40
27-10-30
02-10-29
11-10-29
30-10-29
03-10-31
14-10-30
31-10-41
08-10-39
24-10-32
32-10-29Ch. 1121 Alzheimer's Agents Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-49
09-10-51
27-10-41
02-10-40
11-10-40
30-10-40
03-10-42
14-10-41
31-10-52
08-10-50
24-10-43
32-10-40Ch. 1121 Ophthalmic Antibiotics Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-44
09-10-46
02-10-35
11-10-35
30-10-35
03-10-37
14-10-36
31-10-47
08-10-45
24-10-38
32-10-35
Ch. 1121 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Handbook Pages—Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-43
09-10-45
27-10-35
02-10-34
11-10-34
30-10-34
03-10-36
14-10-35
31-10-46
08-10-44
24-10-37
32-10-34Ch. 1101
1121Requirement for Prescribing Provider National Provider Identifier (NPI) Number on Outpatient Pharmacy Claims—Pharmacy Services 11/12/10 99-10-13 Ch. 1121 Cephalosporins Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-48
09-10-50
27-10-40
02-10-39
11-10-39
30-10-39
03-10-41
14-10-40
31-10-51
08-10-49
24-10-42
32-10-39Ch. 1121 Stimulants and Related Agents Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-47
09-10-49
27-10-39
02-10-38
11-10-38
30-10-38
03-10-40
14-10-39
31-10-50
08-10-48
24-10-41
32-10-38Ch.1121 Platelet Aggregation Inhibitors Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-46
09-10-48
27-10-38
02-10-37
11-10-37
30-10-37
03-10-39
14-10-38
31-10-49
08-10-47
24-10-40
32-10-37Ch. 1121 Ophthalmic Anti-Inflammatories Handbook Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 11/12/10 01-10-45
09-10-47
27-10-37
02-10-36
11-10-36
30-10-36
03-10-38
14-10-37
31-10-48
08-10-46
24-10-39
32-10-36Ch. 1129 Dental Encounter payment for Dental Services Rendered by Rural Health Clinics and Federally Qualified Health Centers 11/15/10 08-10-50 Ch. 1245
1181Payment for Non-Emergency Transportation Services 11/24/10 03-10-43
26-10-01Ch. 1121 Incretin Mimetic/Enhancer Hypoglycemics Pages Pharmacy Services Fall 2010 Preferred Drug List (PDL) Update 12/01/10 01-10-50
09-10-51
27-10-42
02-10-41
11-10-42
30-10-41
03-10-44
14-10-42
31-10-53
08-10-51
24-10-44
32-10-41Ch. 1101 Missed Appointments 12/01/10 99-10-14 Ch. 1101
1150
1241Medical Assistance Program Coverage of the 2010-2011 Influenza Vaccines 12/01/10 99-10-16 Ch. 1121 Oral Buprenorphine Agents Updated Handbook Pages—Pharmacy Services 12/13/10 01-10-51
09-10-52
27-10-42
02-10-42
11-10-42
30-10-42
03-10-45
14-10-43
31-10-54
08-10-52
24-10-45
32-10-42Ch. 1121 Hypoglycemics, TZDs Updated Handbook Pages Pharmacy Services 12/20/10 01-10-52
09-10-53
27-10-43
02-10-43
11-10-43
30-10-43
03-10-46
14-10-44
31-10-55
08-10-53
24-10-46
32-10-43Ch. 1121 Prior Authorization of Topamax/Topiramate Oral Anticonvulsants Updated Handbook Pages Pharmacy Services 12/24/10 01-10-53
09-10-54
27-10-44
02-10-44
11-10-44
30-10-44
03-10-47
14-10-45
31-10-56
08-10-54
24-10-47
32-10-44Ch. 1121 Prior Authorization of Methadone in Analgesics, Narcotic Long Acting Updated Handbook Pages Pharmacy Services 12/24/10 01-10-54
09-10-55
27-10-45
02-10-45
11-10-45
30-10-45
03-10-48
14-10-46
31-10-57
08-10-55
24-10-48
32-10-45— Complex Case Planning 12/28/10 00-10-02 2011 Ch. 1150 2010 HCPCS Updates and Other Procedure Code and Procedure Code/Modifier Combination Changes 01/03/11 99-11-01 Ch. 1123 Change in Billing of Repairs and Replacements for Durable Medical Equipment 01/14/11 24-11-01 Ch. 1101
1150Medical Assistance Electronic Health Records (EHR) Incentive Program For Eligible Professionals 01/25/11 08-11-02
09-11-01
27-11-01
31-11-01
33-11-01Ch. 1101
1150Medical Assistance Electronic Health Records (EHR) Incentive Program for Eligible Hospitals 01/28/11 01-11-01 Ch. 1225 Rescind MA Program Fee Increase for Oral Contraceptives Dispensed by Family Planning Clinics 02/09/11 08-11-03 Ch. 1241 2011 Recommended Childhood and Adolescent Immunization Schedules 03/18/11 01-11-04
08-11-06
09-11-05
31-11-05
33-11-04
Ch. 1101
1150MA Program Outpatient Fee Schedule Decrease for Select Incontinence Products 04/05/11 24-11-02
25-11-02_ Electronic Prescribing Internet-based Application for Enrolled Medicaid Prescribers 04/08/11 03-11-01
09-11-02
14-11-01
18-11-01
24-11-03
27-11-02
31-11-02
33-11-03Ch. 1150 Health Care Benefit Package 12 Updated Employability Assessment Procedure Code List 04/13/11 01-11-02
08-11-04
09-11-03
18-11-02
28-11-01
29-11-01
31-11-03Ch. 1101 SelectPlan for Women Program—Update to Covered Services 04/13/11 01-11-03
08-11-05
09-11-04
24-11-04
28-11-02
31-11-04
33-11-03Ch. 1101
1150Medical Assistance Electronic Health Record (EHR) Incentive Program Application Process for Eligible Professionals (EP) 05/13/11 08-11-07
09-11-06
27-11-03
31-11-06
33-11-05Ch. 1101
1150Medical Assistance Electronic Health (EHR) Incentive Program Application Process For Eligible Hospitals 05/13/11 01-11-05 Ch. 1121 Prior Authorization of Androgenic Agents—Pharmacy Services 05/26/11 01-11-06
09-11-07
27-11-04
02-11-01
11-11-01
30-11-01
03-11-02
14-11-02
31-11-07
08-11-08
24-11-05
32-11-01Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Services05/26/11 01-11-10
09-11-11
27-11-08
02-11-05
11-11-05
30-11-05
03-11-06
14-11-06
31-11-11
08-11-12
24-11-09
32-11-05Ch. 1121 Prior Authorization of Antidepressants, SSRIs—
Pharmacy Services05/26/11 01-11-08
09-11-09
27-11-06
02-11-03
11-11-03
30-11-03
03-11-04
14-11-04
31-11-09
08-11-10
24-11-07
32-11-03Ch. 1121 Prior Authorization of Atypical Antipsychotics—
Pharmacy Services05/26/11 01-11-09
09-11-10
27-11-07
02-11-04
11-11-04
30-11-04
03-11-05
14-11-05
31-11-10
08-11-11
24-11-08
32-11-04Ch. 1121 Prior Authorization of Proton Pump Inhibitors (PPIs)—
Pharmacy Services05/26/11 01-11-07
09-11-08
27-11-05
02-11-02
11-11-02
30-11-02
03-11-03
14-11-03
31-11-09
08-11-09
24-11-06
32-11-02Ch. 1150 Revisions to the Medical Assistance Program Fee Schedule Rates for Select Services 05/30/11 99-11-02 Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services06/08/11 01-11-17 Ch. 1121 Prior Authorization of Antihyperuricemics—Pharmacy Services 06/08/11 01-11-16
09-11-17
27-11-14
02-11-11
11-11-11
30-11-11
03-11-12
14-11-12
31-11-17
08-11-18
24-11-15
32-11-11
Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 06/08/11 01-11-18
09-11-19
27-11-16
02-11-13
11-11-13
30-11-13
03-11-14
14-11-14
31-11-19
08-11-20
24-11-17
32-11-13Ch. 1121 Prior Authorization of Cymbalta Handbook Pages—
Pharmacy Services06/08/11 01-11-18
09-11-19
27-11-16
02-11-13
11-11-13
30-11-13
03-11-14
14-11-14
31-11-19
08-11-20
24-11-17
32-11-13Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 06/08/11 01-11-13
09-11-14
27-11-11
02-11-08
11-11-08
30-11-08
03-11-09
14-11-09
31-11-14
08-11-15
24-11-12
32-11-08Ch. 1121 Prior Authorization of Xolair—Pharmacy Services 06/08/11 01-11-15
09-11-16
27-11-13
02-11-10
11-11-10
30-11-10
03-11-11
14-11-11
31-11-16
08-11-17
24-11-14
32-11-10Ch. 1121 Compounded Hydroxyprogesterone Caproate (17-P)—
Pharmacy Services06/08/11 01-11-19
09-11-20
27-11-17
02-11-14
11-11-14
30-11-14
03-11-15
14-11-15
31-11-20
08-11-21
24-11-18
32-11-14Ch. 1121 Prior Authorization of Duplicate Therapy—Pharmacy Services 06/08/11 01-11-20
09-11-21
27-11-18
02-11-15Ch. 1121 Prior Authorization of Makena—Pharmacy Services 06/21/11 01-11-11
09-11-12
27-11-09
02-11-06
11-11-06
30-11-06
03-11-07
14-11-07
31-11-12
08-11-13
24-11-10
32-11-06Ch. 1121 Prior Authorization of Nuedexta—Pharmacy Services 06/21/11 01-11-12
09-11-13
27-11-10
02-11-07
11-11-07
30-11-07
03-11-08
14-11-08
31-11-12
08-11-14
24-11-11
32-11-07Ch. 1121 Anticoagulants Handbook Pages—Pharmacy Services 07/14/11 01-11-40
09-11-41
27-11-38
02-11-35
11-11-35
30-11-35
03-11-36
14-11-36
31-11-41
08-11-42
24-11-11
32-11-35Ch. 1121 Angiotensin Modulators Handbook Pages—Pharmacy Services 07/14/11 01-11-39
09-11-40
27-11-37
02-11-34
11-11-34
30-11-34
03-11-35
14-11-35
31-11-40
08-11-41
24-11-38
32-11-34Ch. 1121 Opiate Dependence Treatments (Formerly Oral Buprenorphine Agents) Handbook Pages—Pharmacy Services 07/14/11 01-11-34
09-11-35
27-11-32
02-11-29
11-11-29
30-11-29
03-11-30
14-11-30
31-11-35
08-11-36
24-11-33
32-11-29Ch. 1121 Bladder Relaxant Preparations Handbook Pages—
Pharmacy Services07/14/11 01-11-14
09-11-25
27-11-22
02-11-19
11-11-19
30-11-19
03-11-20
14-11-20
31-11-25
08-11-26
24-11-23
32-11-19Ch. 1121 Platelet Aggregation Inhibitors Handbook Pages—
Pharmacy Services07/14/11 01-11-38
09-11-39
27-11-36
02-11-33
11-11-33
30-11-33
03-11-34
14-11-34
31-11-39
08-11-40
24-11-37
32-11-33Ch. 1121 Cephalosporins and Related Agents Handbook Pages—
Pharmacy Services07/14/11 01-11-26
09-11-27
27-11-24
02-11-21
11-11-21
30-11-21
03-11-22
14-11-22
31-11-27
08-11-28
24-11-25
32-11-21Ch. 1121 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Handbook Pages—Pharmacy Services 07/14/11 01-11-29
09-11-30
27-11-27
02-11-24
11-11-24
30-11-24
03-11-25
14-11-25
31-11-30
08-11-31
24-11-28
32-11-24Ch. 1121 Pulmonary Arterial Hypertension Agents, Oral and Inhaled Handbook Pages—Pharmacy Services 07/14/11 01-11-30
09-11-31
27-11-28
02-11-25
11-11-25
30-11-25
03-11-26
14-11-26
31-11-31
08-11-32
24-11-29
32-11-25Ch. 1121 Prior Authorization of Growth Hormones—Pharmacy Services 07/14/11 01-11-42
09-11-43
27-11-40
02-11-37
11-11-37
30-11-37
03-11-38
14-11-38
31-11-43
08-11-44
24-11-41
32-11-25Ch. 1121 Bone Resorption Suppression and Related Agents Handbook Pages—Pharmacy Services 07/14/11 01-11-32
09-11-33
27-11-30
02-11-27
11-11-27
30-11-27
03-11-28
14-11-28 31-11-33
08-11-34
24-11-31
32-11-27Ch. 1121 Multiple Sclerosis Agents Handbook Pages—Pharmacy Services 07/14/11 01-11-41
09-11-42
27-11-39
02-11-36
11-11-36
30-11-36
03-11-37
14-11-37
31-11-42
08-11-43
24-11-40
32-11-36Ch. 1121 Preferred Drug List (PDL) Update August 2011—
Pharmacy Services07/14/11 01-11-37
09-11-38
27-11-35
02-11-32
11-11-32
30-11-32
03-11-33
14-11-33
31-11-38
08-11-39
24-11-36
32-11-32Ch. 1121 Preferred Drug List (PDL) Update August 2011—
Pharmacy Services07/14/11 01-11-35
09-11-36
27-11-33
02-11-30
11-11-30
30-11-30
03-11-31
14-11-31
31-11-36
08-11-37
24-11-34
32-11-32Ch. 1121 Phosphate Binders Handbook Pages—Pharmacy Services 07/14/11 01-11-35
09-11-36
27-11-33
02-11-30
11-11-30
30-11-30
03-11-31
14-11-31
31-11-36
08-11-37
24-11-36
32-11-30Ch. 1121 Analgesics, Narcotics Short Acting Handbook Pages—
Pharmacy Services07/14/11 01-11-23
09-11-24
27-11-21
02-11-18
11-11-18
30-11-18
03-11-19
14-11-19
31-11-24
08-11-25
24-11-22
32-11-18Ch. 1121 Angiotensin Modulator Combinations Handbook Pages—Pharmacy Services 07/14/11 01-11-31
09-11-32
27-11-29
02-11-26
11-11-26
30-11-26
03-11-27
14-11-27
31-11-32
08-11-33
24-11-30
32-11-26Ch. 1121 HIV/AIDS Medications Handbook Pages—Pharmacy Services 07/14/11 01-11-22
09-11-23
27-11-20
02-11-17
11-11-17
30-11-17
03-11-18
14-11-18
31-11-23
08-11-24
24-11-21
32-11-17Ch. 1121 Antifungals, Topical Handbook Pages—Pharmacy Services 07/14/11 01-11-25
09-11-26
27-11-23
02-11-20
11-11-20
30-11-20
03-11-21
14-11-21
31-11-26
08-11-27
24-11-24
32-11-17Ch. 1121 Incretin Memetic/Enhancer Hypoglycemics Handbook Pages—Pharmacy Services 07/14/11 01-11-33
09-11-34
27-11-31
02-11-28
11-11-28
30-11-28
03-11-29
14-11-29
31-11-34
08-11-35
24-11-32
32-11-28Ch. 1121 Oral Contraceptives Handbook Pages—Pharmacy Services 07/14/11 01-11-28
09-11-29
27-11-26
02-11-23
11-11-23
30-11-23
03-11-24
14-11-24
31-11-29
08-11-30
24-11-27
32-11-23Ch. 1121 Prenatal Vitamins Handbook Pages—Pharmacy Services 07/14/11 01-11-36
09-11-37
27-11-34
02-11-31
11-11-31
30-11-31
03-11-32
14-11-32
31-11-87
08-11-38
24-11-35
32-11-31Ch. 1121 Colony Stimulating Factors Handbook Pages—
Pharmacy Services07/14/11 01-11-27
09-11-28
27-11-25
02-11-22
11-11-22
30-11-22
03-11-23
14-11-23
31-11-28
08-11-29
24-11-26
32-11-22Ch. 1121 Antiemetics (Promethazine)—Pharmacy Service 07/19/97 01-11-21
09-11-22
27-11-19
02-11-16
11-11-16
30-11-16
03-11-17
14-11-17
31-11-22
08-11-23
24-11-20
32-11-16Ch. 1121 Correction to Preferred Drug List (PDL) Update August 2011—Pharmacy Services 08/08/11 01-11-45
02-11-39
03-11-40
08-11-46
09-11-45
11-11-39
14-11-40
24-11-46
27-11-42
30-11-39
31-11-44
32-11-39
33-11-07Ch. 1121 Procedures to Submit Requests for Prior Authorization of Selected Medications by Facsimile (Fax)—Pharmacy Services 08/08/11 01-11-46
02-11-40
11-11-40
30-11-40
09-11-46
27-11-43
03-11-41
14-11-41
31-11-45
08-11-47
24-11-47
32-11-40
33-11-08Ch. 1150 2011 HCPCS Updates and Other Procedure Code Changes 08/08/11 00-11-04 Ch. 1101 Provider Screening of Employees and Contractors for Exclusion From Participation in Federal Health Care Programs and the Effect of Exclusion on Participation 8/15/11 99-11-05 Ch. 1121 Prior Authorization of Synagis—Pharmacy Services 08/15/11 01-11-47
09-11-47
27-11-44
02-11-41
11-11-41
30-11-41
03-11-42
14-11-42
31-11-46
08-11-48
24-11-48
32-11-41
33-11-09Ch. 1121 Early Refills—Pharmacy Services 08/15/11 01-11-47
09-11-47
27-11-44
02-11-41
11-11-41
30-11-41
03-11-42
14-11-42
31-11-46
08-11-48
24-11-48
32-11-41
03-11-09— Specialty Pharmacy Drug Program
—Updated List of Covered Drugs
—Pharmacy Services09/09/11 99-11-60 Ch. 1149 Medical Assistance Dental Benefit Changes 9/26/11 27-11-47
08-11-51Ch. 1163 Revised Payment Policy for Hospital Readmissions 10/3/11 01-11-44 — Discontinued Mailing of Medical Assistance Bulletins 09/26/11 99-11-08 Ch. 1150 Prudent Payment of Claims 09/30/11 99-11-07 Ch. 1163 Revised Payment Policy for Hospital Readmission 09/30/11 01-11-44 Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Services 10/17/11 01-11-48
09-11-48
27-11-45
02-11-42
11-11-42
30-11-42
03-11-43
14-11-43
31-11-47
08-11-49
24-11-49
32-11-42
33-11-10Ch. 1121 Prior Authorization of Xyrem—Pharmacy Services 10/17/11 01-11-49
09-11-49
27-11-46
02-11-43
11-11-43
30-11-43
03-11-44
14-11-44
31-11-48
08-11-50
24-11-50
32-11-43
33-11-11— 5010/D.0 Instructions to be Ready for Electronic Transaction Upgrades 10/27/11 99-11-09 Ch. 1121 Prior Authorization of Benzodiazepines—Pharmacy Services 10/28/11 01-11-50 Ch. 1121 Prior Authorization of Skeletal Muscle Relaxants—
Pharmacy Services10/28/11 01-11-50
09-11-50
27-11-48
02-11-44
11-11-44
30-11-44
03-11-45
14-11-45
31-11-49
08-11-52
24-11-51
32-11-44
33-11-12Ch. 1121 Prior Authorization of Early Refills Exemptions and Automated Approvals—Pharmacy Services 11/02/11 01-11-53
09-11-53
27-11-51
02-11-47
11-11-48
30-11-47
03-11-48
14-11-48
31-11-52
08-11-55
24-11-54
32-11-47
33-11-15Ch. 1150 Announcing the Federally Mandated Implementation of the National Correct Coding Initiative (NCCI) in the Pennsylvania Department of Public Welfare's Medical Assistance Program 11/10/11 99-11-10 Ch. 1150 ClaimCheck® Claims Criteria—Update 11/23/11 99-11-11 Ch. 1101
1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2 for Eligible Professionals (EP) 12/02/11 08-11-56
09-11-54
27-11-52
31-11-53
33-11-16Ch. 1101
1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2 for Eligible Hospitals (EH) 12/02/11 01-11-54 Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 12/03/11 01-11-57
09-11-57
27-11-55
33-11-19
02-11-50
11-11-51
30-11-50
03-11-51
14-11-51
31-11-56
08-11-59
24-11-57
32-11-50Ch. 1121 Prior Authorization of Erythropoiesis Stimulating Agents—Pharmacy Services 12/03/11 01-11-56
09-11-56
27-11-54
33-11-18
02-11-49
11-11-50
30-11-49
03-11-50
14-11-50
31-11-55
08-11-58
24-11-56
32-11-49Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 12/09/11 01-11-52
09-11-52
27-11-50
02-11-46
11-11-46
30-11-46
03-11-47
14-11-47
31-11-51
08-11-54
24-11-53
32-11-46
33-11-14Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/10/11 01-11-55
09-11-55
27-11-53
33-11-17
02-11-48
11-11-49
30-11-48
03-11-49
14-11-49
31-11-54
08-11-57
24-11-55
32-11-48Ch. 1121 Medical Assistance Pharmacy Benefit Package Change 12/30/11 99-11-58
14-11-52
18-11-03
24-11-58
27-11-56
31-11-57
33-11-202012 Ch. 1121 Prior Authorization of Antidepressants, Other—
Pharmacy Services01/26/12 01-12-02
09-12-02
27-12-02
33-12-02
02-12-02
11-12-02
30-12-02
03-12-02
14-12-02
31-12-02
08-12-02
24-12-02
32-12-02Ch. 1121 Prior Authorization of Antihypertensives, Sympatholytic—Pharmacy Services 01/26/12 01-12-04
08-12-04
14-12-04
30-12-04
33-12-04
02-12-04
09-12-04
24-12-04
31-12-04
03-12-04
11-12-04
27-12-04
32-12-04Ch. 1121 Prior Authorization of Antihistamines, Minimally Sedating—Pharmacy Services 01/26/12 01-12-03
09-12-03
27-12-03
33-12-03
02-12-03
11-12-03
30-12-03
03-12-03
14-12-03
31-12-03
08-12-03
24-12-03
32-12-03Ch. 1121 Preferred Drug List (PDL) Update February 2012—
Pharmacy Services01/26/12 01-12-01
09-12-01
27-12-01
33-12-01
02-12-01
11-12-01
30-12-01
03-12-01
14-12-01
31-12-01
08-12-01
24-12-01
32-12-01Ch. 1121 Prior Authorization of Cymbalta—Pharmacy Services 01/26/12 01-12-06
09-12-06
27-12-06
33-12-06
02-12-06
11-12-06
30-12-06
03-12-06
14-12-06
31-12-06
08-12-06
24-12-06
32-12-06Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—Pharmacy Services 01/26/12 01-12-05
09-12-05
27-12-05
33-12-05
02-12-05
11-12-05
30-12-05
03-12-05
14-12-05
31-12-05
08-12-05
24-12-05
32-12-05Ch. 1121 Prior Authorization of Emollients—Pharmacy Services 01/30/12 01-12-08
09-12-08
27-12-08
33-12-08
02-12-08
11-12-08
30-12-08
03-12-08
14-12-08
31-12-08
08-12-08
24-12-08
32-12-08Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 01/30/12 01-12-07
09-12-07
27-12-07
33-12-07
02-12-07
11-12-07
30-12-07
03-12-07
14-12-07
31-12-07
08-12-07
24-12-07
32-12-07Ch. 1121 Prior Authorization of Intranasal Rhinitis Agents—
Pharmacy Services02/01/12 01-12-11
09-12-11
27-12-11
33-12-11
02-12-11
11-12-11
30-12-11
03-12-11
14-12-11
31-12-11
08-12-11
24-12-11
32-12-11Ch. 1121 Prior Authorization of Enzyme Replacements, Gauchers Disease—Pharmacy Services 02/01/12 01-12-09
08-12-09
14-12-09
30-12-09
33-12-09
02-12-09
09-12-09
24-12-09
31-12-09
03-12-09
11-12-09
27-12-09
32-12-09Ch. 1121 Prior Authorization of Immunomodulators, Atopic Dermatitis—Pharmacy Services 02/01/12 01-12-10
08-12-10
14-12-10
30-12-10
33-12-10
02-12-10
09-12-10
24-12-10
31-12-10
03-12-10
11-12-10
27-12-10
32-12-10Ch. 1121 Prior Authorization of Iron, Parenteral—Pharmacy Services 02/01/12 01-12-12
08-12-12
14-12-12
30-12-12
33-12-12
02-12-12
09-12-12
24-12-12
31-12-12
03-12-12
11-12-12
27-12-12
32-12-12Ch. 1121 Prior Authorization of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)—Pharmacy Services 02/03/12 01-12-15
09-12-15
27-12-15
33-12-15
02-12-15
11-12-15
30-12-15
03-12-15
14-12-15
31-12-15
08-12-15
24-12-15
32-12-15Ch. 1121 Prior Authorization of Myalgia and Neuropathy Agents—Pharmacy Services 02/03/12 01-12-14
08-12-14
14-12-14
30-12-14
33-12-14
02-12-14
09-12-14
24-12-14
31-12-14
03-12-14
11-12-14
27-12-14
32-12-14Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 02/06/12 01-12-19
09-12-19
27-12-19
33-12-19
02-12-19
11-12-19
30-12-19
03-12-19
14-12-19
31-12-19
08-12-19
24-12-19
32-12-19Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 02/06/12 01-12-13
09-12-13
27-12-13
33-12-13
02-12-13
11-12-13
30-12-13
03-12-13
14-12-13
31-12-13
08-12-13
24-12-13
32-12-13Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Services 02/06/12 01-12-21
09-12-21
27-12-21
33-12-21
02-12-21
11-12-21
30-12-21
03-12-21
14-12-21
31-12-21
08-12-21
24-12-21
32-12-21Ch. 1121 Prior Authorization of Otic Anti-Infectives and Anesthetics—Pharmacy Services 02/13/12 01-12-18
08-12-18
14-12-18
30-12-18
33-12-18
02-12-18
09-12-18
24-12-18
31-12-18
03-12-18
11-12-18
27-12-18
32-12-18Ch. 1121 Prior Authorization of Ophthalmic Antibiotic-Steroid Combinations—Pharmacy Services 02/13/12 01-12-17
08-12-17
14-12-17
30-12-17
33-12-17
02-12-17
09-12-17
24-12-17
31-12-17
03-12-17
11-12-17
27-12-17
02-12-17Ch. 1121 Prior Authorization of Smoking Cessation Products—
Pharmacy Services02/14/12 01-12-20
09-12-20
27-12-20
03-12-20
02-12-20
11-12-20
30-12-20
03-12-20
14-12-20
31-12-20
08-12-20
24-12-20
32-12-20Ch. 1128 Processing of Medicare Renal Dialysis Services Crossover Claims for Procedure Code 90999 2/21/12 30-12-22 Ch. 1101
1150Correction to Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2 for Eligible Professionals (EP) 03/08/12 08-12-22
09-12-24
27-12-22
31-12-22
33-12-22Ch. 1121 Prior Authorization of Myalgia and Neuropathy Agents—Pharmacy Services 03/18/12 01-12-22
09-12-23
27-12-23
33-12-23
02-12-22
11-12-22
30-12-23
03-12-22
14-12-22
31-12-23
08-12-23
24-12-22
32-12-22Ch. 1121 Prior Authorization of Antibiotics, Topical—Pharmacy Services 03/18/12 01-12-24
09-12-25
27-12-24
33-12-25
02-12-23
11-12-23
30-12-24
03-12-23
14-12-23
31-12-25
08-12-25
24-12-23
32-12-23
Ch. 1123 Removal of NU Pricing Modifier from Procedure Codes for Oxygen Contents 03/20/12 24-12-24
25-12-01Ch. 1121 Prior Authorization of Oncology Agents, Oral—
Pharmacy Services04/02/12 01-12-16
09-12-16
27-12-16
33-12-16
02-12-16
11-12-16
30-12-16
03-12-16
14-12-16
31-12-16
08-12-16
24-12-16
32-12-16— Provider Electronic Solutions (PES) Software v3.59 replaces v3.58 04/06/12 99-12-01 Ch. 1101
Ch. 1150
Ch. 1241Updates to the Medical Assistance Program Fee Schedule for the Administration of Prevnar 13® Vaccine 04/06/12 01-12-25
08-12-26
09-12-26
31-12-26
33-12-26Ch. 1101 Updates to Medical Assistance Copayment Policy 04/16/12 99-12-03 Ch. 1121 Changes to the Drug Cost Component of Payment for Brand Name and Generic Drugs—Pharmacy Services 05/01/12 01-12-28
09-12-29
27-12-26
33-12-28
02-12-25
11-12-25
30-12-26
03-12-25
14-12-25
31-12-29
08-12-28
24-12-26
32-12-25Ch. 1121 Changes to the Dispensing Fee Component of Payment for Brand Name and Generic Drugs—Pharmacy Services 05/01/12 01-12-27
09-12-28
27-12-25
33-12-27
02-12-24
11-12-24
30-12-25
03-12-24
14-12-24
31-12-24
08-12-27
24-12-25
32-12-24Ch. 1149 Revision of Online Training Module for the Application of Topical Fluoride Varnish 5/1/12 09-12-27
31-12-27Ch. 1163 Newborn Payment Policy for Acute Care General Hospitals 5/4/12 01-12-26 — Specialty Pharmacy Drug Program—Updated List of Covered Drugs—Pharmacy Services 05/11/12 99-12-04 — Electronic Forms 05/11/12 99-12-02 Ch. 1121 Prior Authorization of Makena—Pharmacy Services 05/11/12 01-12-29
02-12-26
03-12-26
08-12-29
09-12-30
11-12-26
14-12-26
24-12-27
27-12-27
30-12-27
31-12-30
32-12-26
33-12-29Ch. 1150 Consultations Performed Using Telemedicine 5/23/12 09-12-31
31-12-31
33-12-30Ch. 1229 HealthChoices Physical Health Managed Care Expansion 5/25/12 99-12-05 — Provider Preventable Conditions 06/15/12 01-12-30
03-12-27
09-12-32
18-12-01
31-12-32
33-12-31
02-12-27
08-12-30
14-12-27
27-12-28
32-12-27
47-12-01— FQHC Change in Scope of Service 06/20/12 08-12-31 Ch. 1150 2012 HCPCS Updates and Other Procedure Code Changes 06/25/12 99-12-06 Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancers Hypoglycemics—Pharmacy Services 07/11/12 01-12-32
09-12-34
27-12-30
33-12-33
02-12-29
11-12-28
30-12-29
03-12-29
14-12-29
31-12-34
08-12-33
24-12-29
32-12-29Ch. 1121 Preferred Drug List (PDL) Update August 2012—
Pharmacy Services07/12/12 01-12-33
09-12-35
27-12-31
33-12-34
02-12-30
11-12-29
30-12-37
03-12-30
14-12-30
31-12-35
08-12-34
24-12-30
32-12-30Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Services 07/13/12 01-12-36
08-12-36
14-12-31
30-12-31
33-12-35
02-12-31
09-12-37
24-12-32
31-12-37
03-12-31
11-12-30
27-12-33
32-12-31
Ch. 1121 Prior Authorization of Platelet Aggregation Inhibitors—Pharmacy Services 08/03/12 01-12-45
09-12-43
27-12-39
33-12-41
02-12-37
11-12-36
30-12-37
03-12-37
14-12-37
31-12-43
08-12-42
24-12-38
32-12-37Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—Pharmacy Services 08/03/12 01-12-44
09-12-42
27-12-38
33-12-40
02-12-36
11-12-35
30-12-36
03-12-36
14-12-36
31-12-42
08-12-41
24-12-37
32-12-36Ch. 1121 Prior Authorization of Benign Prostatic Hyperplasia (BPH) Treatments—Pharmacy Services 08/03/12 01-12-41
09-12-40
27-12-36
33-12-38
02-12-34
11-12-33
30-12-34
03-12-34
14-12-34
31-12-40
08-12-39
24-12-35
32-12-34Ch. 1121 Prior Authorization of Erythropoiesis Stimulating Proteins—Pharmacy Services 08/03/12 01-12-42
09-12-41
27-12-37
33-12-39
02-12-35
11-12-34
30-12-35
03-12-35
14-12-35
31-12-41
08-12-40
24-12-36
32-12-35Ch. 1121 Prior Authorization of Antibiotics, GI—Pharmacy Services 08/03/12 01-12-39
09-12-38
27-12-34
33-12-36
02-12-32
11-12-31
30-12-32
03-12-32
14-12-32
31-12-38
08-12-37
24-12-33
32-12-32Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 08/03/12 01-12-40
09-12-39
27-12-35
33-12-37
02-12-33
11-12-32
30-12-33
03-12-33
14-12-33
31-12-39
08-12-38
24-12-34
32-12-33Ch. 1121 Prior Authorization of Lipotropics, Statins—Pharmacy Services 08/03/12 01-12-46
09-12-44
27-12-40
33-12-42
02-12-38
11-12-37
30-12-38
03-12-38
14-12-37
31-12-44
08-12-43
24-12-39
32-12-38Ch. 1121 Prior Authorization of Growth Factors—Pharmacy Services 08/07/12 01-12-31
08-12-32
14-12-28
30-12-28
33-12-32
02-12-28
09-12-33
24-12-28
31-12-33
03-12-28
11-12-27
27-12-29
32-12-28Ch. 1229 HealthChoices Physical Health Managed Care New West Zone Expansion 08/08/12 99-12-08 Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions 08/31/12 99-12-10 Ch. 1150 Information Regarding Peritoneal Dialysis Treatment 09/13/12 01-12-50
30-12-43
31-12-49Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Changes for Renal Dialysis Services 09/13/12 30-12-39
13-12-45Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 09/13/12 01-12-49
09-12-47
27-12-43
33-12-45
02-12-41
11-12-40
30-12-42
03-12-41
14-12-41
31-12-48
08-12-46
24-12-42
32-12-41Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 09/13/12 01-12-48
09-12-46
27-12-42
33-12-44
02-12-40
11-12-39
30-12-41
03-12-40
14-12-40
31-12-47
08-12-45
24-12-41
32-12-40Ch. 1121 Prior Authorization of Bronchodilators, Anticholinergic—Pharmacy Services 09/13/12 01-12-47
09-12-45
27-12-41
33-12-43
02-12-39
11-12-38
30-12-40
03-12-39
14-12-39
31-12-46
08-12-44
24-12-40
32-12-39Ch. 1150 New Procedure Codes for Tobacco Cessation Counseling Services 10/03/12 99-12-09 Ch. 1101 Delaying Alternative Cost Sharing for Families of Children with Disabilities with Incomes Over 200% of the Federal Poverty Income Guidelines 10/15/12 99-12-15 Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 10/22/12 01-12-53
09-12-50
27-12-46
33-12-48
02-12-44
11-12-43
30-12-46
03-12-44
14-12-44
31-12-52
08-12-49
24-12-45
32-12-44Ch. 1121 Prior Authorization of Angiotensin Modulator Combinations—Pharmacy Services 10/22/012 01-12-52
02-12-43
03-12-43
08-12-48
09-12-49
11-12-42
14-12-43
24-12-44
27-12-45
30-12-45
31-12-51
32-12-43
33-12-47Ch. 1150 Federally Mandated Implementation: Updates to National Correct Coding Initiative (NCCI) 10/26/12 99-12-12 Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Services10/30/12 01-12-54
08-12-50
14-12-45
30-12-47
33-12-49
02-12-45
09-12-51
24-12-46
31-12-53
03-12-45
11-12-44
27-12-47
32-12-45Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services10/30/12 01-12-56
08-12-52
14-12-47
30-12-49
33-12-51
02-12-47
09-12-53
24-12-48
31-12-55
03-12-47
11-12-46
27-12-49
32-12-47Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 10/30/12 01-12-57
08-12-53
14-12-48
30-12-50
33-12-52
02-12-48
09-12-54
24-12-49
31-12-56
03-12-48
11-12-47
27-12-50
32-12-48(Editor's Note: This document continues with the Department of Human Services (DHS) in Part III at 47 Pa.B. 5483 (September 2, 2017).)
(Editor's Note: This document continues from Part II which begins at 47 Pa.B. 5303 (September 2, 2017).)
Year Code Citation(s) Subject Date Issued Bulletin Number Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 10/30/12 01-12-55
08-12-51
14-12-46
30-12-48
33-12-50
02-12-46
09-12-52
24-12-47
31-12-54
03-12-46
11-12-45
27-12-48
32-12-46Ch.1123 Prior Authorization Requirements for the Rental of Medical Appliances and Durable Medical Equipment 12/10/12 24-12-55
25-12-02Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions 12/10/12 99-12-13 Ch. 1101
Ch. 1150
Ch. 1149Addition to the Medical Assistance Program Fee Schedule for Administration of Flu Vaccine for Intradermal Use: Fluzone Intradermal® 12/13/12 01-12-64
08-12-59
09-12-60
31-12-62
33-12-58Ch. 1150 NPI Requirements on All Claim Submission Media 12/19/12 99-12-14 Ch. 1121 Anticoagulants—New Quantity Limit for Low Molecular Weight Heparins and Arixtra (Fondaparinux)—Pharmacy Services 12/21/12 01-12-63
09-12-59
27-12-55
33-12-57
02-12-53
11-12-52
30-12-55
03-12-53
14-12-53
31-12-61
08-12-58
24-12-54
32-12-53Ch. 1121 Prior Authorization of Kalydeco—Pharmacy 12/21/12 01-12-60
09-12-56
27-12-52
33-12-54
02-12-50
11-12-49
30-12-52
03-12-50
14-12-50
31-12-58
08-12-55
24-12-51
32-12-50Ch. 1121 Prior Authorization of Hypoglycemics, TZDs—
Pharmacy Services12/21/12 01-12-61
09-12-57
27-12-53
33-12-55
02-12-51
11-12-50
30-12-53
03-12-51
14-12-51
31-12-59
08-12-56
24-12-52
32-12-51Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 12/21/12 01-12-62
09-12-58
27-12-54
33-12-56
02-12-52
11-12-51
30-12-54
03-12-52
14-12-52
31-12-60
08-12-57
24-12-53
32-12-52Ch. 1121 Prior Authorization of Korlym—Pharmacy Services 12/21/12 01-12-59
09-12-55
27-12-51
33-12-53
02-12-49
11-12-48
30-12-51
03-12-49
14-12-49
31-12-57
08-12-54
24-12-50
32-12-49Ch. 1150 Clinical Laboratory Improvement Amendments Requirements 12/28/12 01-12-67
08-12-62
09-12-63
28-12-01
31-13-65
33-13-612013 Ch. 1121 Prior Authorization of Antipsoriatics Topical—
Pharmacy Services1/7/13 01-13-01
09-13-01
27-13-01
33-13-01
02-13-01
11-13-01
30-13-01
03-13-01
14-13-01
31-13-01
08-13-01
24-13-01
32-13-01Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 1/7/13 01-13-02
09-13-02
27-13-02
33-13-02
02-13-02
11-13-02
30-13-02
03-13-02
14-13-02
31-13-02
08-13-02
24-13-02
32-13-02Ch. 1121 Prior Authorization of Diabetic Strips—Pharmacy Services 1/7/13 01-13-03
09-13-03
27-13-03
33-13-03
02-13-03
11-13-03
30-13-03
03-13-03
14-13-03
31-13-03
08-13-03
24-13-03
32-13-03Ch. 1121 Prior Authorization of Glucocorticoids Oral—
Pharmacy Services1/7/13 01-13-04
09-13-04
27-13-04
33-13-04
02-13-04
11-13-04
30-13-04
03-13-04
14-13-04
31-13-04
08-13-04
24-13-04
32-13-04Ch. 1121 Prior Authorization of Leukotriene Modifiers—
Pharmacy Services1/7/13 01-13-05
09-13-05
27-13-05
33-13-05
02-13-05
11-13-05
30-13-05
03-13-05
14-13-05
31-13-05
08-13-05
24-13-05
32-13-05Ch. 1121 Prior Authorization of Neuropathic Pain Agents (Formerly Myalgia and Neuropathy Agents)—Pharmacy Services 1/7/13 01-13-06
09-13-06
27-13-06
33-13-06
02-13-06
11-13-06
30-13-06
03-13-06
14-13-06
31-13-06
08-13-06
24-13-06
32-13-06Ch. 1121 Prior Authorization of Oncology Agents Breast Cancer—Pharmacy Services 1/7/13 01-13-07
08-13-07
14-13-07
32-13-07
02-13-07
09-13-07
24-13-07
30-13-07
03-13-07
11-13-07
27-13-07
31-13-07
33-13-07Ch. 1121 Prior Authorization of Smoking Cessation Products—
Pharmacy Services1/7/13 01-13-08
09-13-08
27-13-08
33-13-08
02-13-08
11-13-08
30-13-08
03-13-08
14-13-08
31-13-08
08-13-08
24-13-08
32-13-08Ch. 1121 Prior Authorization of Diabetic Meters—Pharmacy Services 1/7/13 01-13-09
09-13-09
27-13-09
33-13-09
02-13-09
11-13-09
30-13-09
03-13-09
14-13-09
31-13-09
08-13-09
24-13-09
32-13-09Ch. 1229 HealthChoices Physical Health Managed Care New East Zone Expansion 01/18/13 99-13-02 Ch. 1121 Preferred Drug List (PDL) Update January 15, 2013—Pharmacy Services 01/22/13 01-13-11
09-13-11
27-13-11
33-13-11
02-13-10
11-13-10
30-13-10
03-13-10
14-13-10
31-13-12
08-13-11
24-13-11
32-13-10Ch. 1150 Medical Assistance Program Fee Increase for Select Primary Care Services and Physician Attestation Form 01/22/13 31-13-11 Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 1/25/13 01-13-12
08-13-12
14-13-11
30-13-11
33-13-12
02-13-11
09-13-12
24-13-12
31-13-13
03-13-11
11-13-11
27-13-12
32-13-11Ch. 1150 Medical Assistance Program Fee Increase for Select Primary Care Services and Physician Attestation Form 01/22/13 31-13-11 Ch. 1101
Ch. 1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2013 for Eligible Professionals (EP) 2/1/13 08-13-10
09-13-10
27-13-10
31-13-10
33-13-10Ch. 1101
Ch. 1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2013 for Eligible Hospitals (EH) 2/1/13 01-13-10 Ch. 1101 Updated Procedures for Submitting the Deficit Reduction Act of 2005 Attestation Form 02/14/13 99-13-04 Ch. 1229 Continued Existence of the Fee-For-Service Delivery System in HealthChoices Zones and Enrollment of Breast and Cervical Cancer Prevention and Treatment (BCCPT) Recipients in HealthChoices 02/22/13 99-13-05 Ch. 1121 Prior Authorization of Analgesics Narcotic Short Acting—Pharmacy Services 3/29/13 01-13-16
08-13-16
14-13-15
30-13-15
33-13-17
02-13-15
09-13-17
24-13-16
31-13-18
03-13-15
11-13-15
27-13-16
32-13-15Ch. 1121 Prior Authorization of Bladder Relaxant Preparations—Pharmacy Services 3/29/13 01-13-14
09-13-15
27-13-14
33-13-15
02-13-13
11-13-13
30-13-13
03-13-13
14-13-13
31-13-16
08-13-14
24-13-14
32-13-13Ch. 1121 Prior Authorization of Bronchodilators Beta Agonists Short Acting Agents—Pharmacy Services 3/29/13 01-13-17
08-13-17
14-13-16
30-13-16
33-13-18
02-13-16
09-13-18
24-13-17
31-13-19
03-13-16
11-13-16
27-13-17
32-13-16Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 3/29/13 01-13-13
08-13-13
14-13-12
30-13-12
33-13-14
02-13-12
09-13-14
24-13-13
31-13-15
03-13-12
11-13-12
27-13-13
32-13-12Ch. 1121 Prior Authorization of Chronic Obstructive Pulmonary Disease (COPD) Agents—Pharmacy Services 3/29/13 01-13-15
09-13-16
27-13-15
33-13-16
02-13-14
11-13-14
30-13-14
03-13-14
14-13-14
31-13-17
08-13-15
24-13-15
32-13-14Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions for Procedure Code K0606 04/01/13 24-13-10
25-13-01Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions 04/15/13 99-13-03 Ch. 1121 Medical Assistance Pharmacy Benefit Package Update 04/22/13 99-13-20
14-13-17
18-13-01
24-13-18
17-13-18
31-13-21
33-13-20Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 5/3/13 01-13-19
09-13-21
27-13-19
33-13-21
02-13-17
11-13-17
30-13-17
03-13-17
14-13-18
31-13-22
08-13-19
24-13-19
32-13-17Ch. 1101 Revised Physician Attestation Form for Primary Care Services 5/3/13 31-13-32 Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents Oral and Inhaled—
Pharmacy Services5/3/13 01-13-23
09-13-25
27-13-23
33-13-25
02-13-21
11-13-21
30-13-21
03-13-21
14-13-22
31-13-26
08-13-23
24-13-23
32-13-21Ch. 1121 Prior Authorization of Lyrica (pregabalin) Neuropathic Pain Agents and Oral Anticonvulsants—Pharmacy Services 5/3/13 01-13-25
09-13-27
27-13-25
33-13-27
02-13-23
11-13-23
30-13-23
03-13-23
14-13-24
31-13-28
08-13-25
24-13-25
32-13-23Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services5/3/13 01-13-20
09-13-22
27-13-20
33-13-22
02-13-18
11-13-18
30-13-18
03-13-18
14-13-19
31-13-23
08-13-20
24-13-20
32-13-18Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and Type B)—Pharmacy Services 5/3/13 01-13-21
09-13-23
27-13-21
33-13-23
02-13-19
11-13-19
30-13-19
03-13-19
14-13-20
31-13-24
08-13-21
24-13-21
32-13-19Ch. 1121 Prior Authorization of Benzodiazepines; Analgesics Narcotic Long Acting; and Analgesics Narcotic Short Acting—Pharmacy Services 5/3/13 01-13-26
09-13-28
27-13-26
33-13-28
02-13-24
11-13-24
30-13-24
03-13-24
14-13-25
31-13-29
08-13-26
24-13-26
32-13-24Ch. 1121 Medicare Part D Coverage of Barbiturates and Benzodiazepines—Pharmacy Services 5/3/13 01-13-28
08-13-28
14-13-27
30-13-26
33-13-30
02-13-26
09-13-30
24-13-28
31-13-31
03-13-26
11-13-26
27-13-28
32-13-26Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 5/3/13 01-13-27
09-13-29
27-13-27
33-13-29
02-13-25
11-13-25
30-13-25
03-13-25
14-13-26
31-13-30
08-13-27
24-13-27
32-13-25Ch. 1121 340B Drug Pricing Program Provider Requirements and Billing Instructions—Pharmacy Services 5/16/13 99-13-08 Ch. 1101 Application of InvestiClaimTM Analytics to Select Claims 5/17/13 99-13-09 Ch. 1150 Implementation of the Medical Assistance Program's Physician Fee Increases for Select Primary Care Services 5/23/13 31-13-34 Ch. 1150 Addition to the Medical Assistance Program Fee Schedule for Administration of Flu Vaccine Derived from Cell Cultures: Flucelvax 5/25/13 01-13-18
08-13-18
09-13-19
31-13-20
33-13-19Ch. 1121 Prior Authorization of Androgenic Agents—Pharmacy Services 5/31/13 01-13-22
02-13-20
03-13-20
08-13-22
09-13-24
11-13-20
14-13-21
24-13-22
27-13-22
30-13-20
31-13-25
32-13-20
33-13-24Ch. 1121 Prior Authorization of H.P. Acthar Gel—Pharmacy Services 5/31/13 01-13-24
02-13-22
03-13-22
08-13-24
09-13-26
11-13-22
14-13-23
24-13-24
27-13-24
30-13-22
31-13-27
32-13-22
33-13-26Ch. 1150 2013 HCPCS Updates and Other Procedure Code Changes 6/24/13 99-13-07 Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 7/2/13 01-13-38
02-13-34
03-13-34
08-13-36
09-13-38
11-13-34
14-13-35
24-13-36
27-13-36
30-13-34
31-13-42
32-13-34
33-13-38Ch. 1121 Prior Authorization of Antiparasitics Topical—
Pharmacy Services7/2/13 01-13-37
02-13-33
03-13-33
08-13-35
09-13-37
11-13-33
14-13-34
24-13-35
27-13-35
30-13-33
31-13-41
32-13-33
33-13-37Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services7/2/13 01-13-39
02-13-35
03-13-35
08-13-37
09-13-39
11-13-35
14-13-36
24-13-37
27-13-37
30-13-35
31-13-43
32-13-35
33-13-39Ch. 1150 Hospital Payment Arrangements 1 and 2 for Emergency Room Services 7/2/13 01-13-29
31-13-33Ch. 1121 Prior Authorization of Vasodilators Coronary—
Pharmacy Services7/2/13 01-13-36
02-13-32
03-13-32
08-13-34
09-13-36
11-13-32
14-13-33
24-13-34
27-13-34
30-13-32
31-13-40
32-13-32
33-13-36Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 7/2/13 01-13-34
02-13-30
03-13-30
08-13-32
09-13-34
11-13-30
14-13-31
24-13-32
27-13-32
30-13-30
31-13-38
32-13-30
33-13-34Ch. 1121 Prior Authorization of H. Pylori Treatments—
Pharmacy Services7/2/13 01-13-32
02-13-28
03-13-28
08-13-30
09-13-32
11-13-28
14-13-29
24-13-30
27-13-30
30-13-28
31-13-36
32-13-28
33-13-32Ch. 1121 Preferred Drug List (PDL) Update July 24, 2013—
Pharmacy Services7/7/13 01-13-31
09-13-31
27-13-29
33-13-31
02-13-27
11-13-27
30-13-27
03-13-27
14-13-28
31-13-35
08-13-29
24-13-29
32-13-27Ch. 1121 Prior Authorization of Colony Stimulating Factors—
Pharmacy Services7/13/13 01-13-33
09-13-33
27-13-31
33-13-33
02-13-29
11-13-29
30-13-29
03-13-29
14-13-30
31-13-37
08-13-31
24-13-31
32-13-29Ch. 1121 Prior Authorization of Irritable Bowel Syndrome Agents—Pharmacy Services 7/13/13 01-13-35
09-13-35
27-13-33
33-13-35
02-13-31
11-13-31
30-13-31
03-13-31
14-13-32
31-13-39
08-13-33
24-13-33
32-13-31Ch. 1121 Prior Authorization of Acne Agents Oral—
Doxycycline—Pharmacy Services7/22/13 01-13-40
08-13-38
14-13-37
30-13-36
33-13-40
02-13-36
09-13-40
24-13-38
31-13-44
03-13-36
11-13-36
27-13-38
32-13-36Ch. 1127
Ch. 1150Changes to the Payment Structure for Birth Center Services 8/29/13 09-13-13
31-13-14
33-13-13
47-13-01Ch. 1101 Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2014 for Eligible Hospitals (EH) 9/20/13 01-13-41 Ch. 1101 Implementation of ADA Claim Form—Version 2012 and Elimination of ADA Claim Form—Version 2006 9/20/13 17-13-01
19-13-01
20-13-01
27-13-39
31-13-45Ch. 1101
Ch. 1149
Ch. 1129Correction to the Procedures for Reporting of Other Provider Preventable Conditions (OPPCs) for Federally Qualified Health Centers Rural Health Clinics and Dentists 10/2/13 08-13-39
27-13-41Ch. 1101 Application of InvestiClaimTM Analytics to Select Claims—Update 10/4/13 99-13-12 Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 11/4/13 01-13-45
09-13-45
27-13-45
33-13-44
02-13-40
11-13-40
30-13-40
03-13-40
14-13-41
31-13-50
08-13-43
24-13-42
32-13-40Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Services11/4/13 01-13-44
09-13-44
27-13-44
33-13-43
02-13-39
11-13-39
30-13-39
03-13-39
14-13-40
31-13-49
08-13-42
24-13-41
32-13-39Ch. 1121 Prior Authorization of Benign Prostatic Hyperplasia (BPH) Treatment—Pharmacy Services 11/4/13 01-13-46
09-13-46
27-13-46
33-13-45
02-13-41
11-13-41
30-13-41
03-13-41
14-13-42
31-13-51
08-13-44
24-13-43
32-13-41Ch. 1121 Prior Authorization of HIV/AIDS Medications—
Pharmacy Services11/4/13 01-13-47
09-13-47
27-13-47
33-13-46
02-13-42
11-13-42
30-13-42
03-13-42
14-13-43
31-13-52
08-13-45
24-13-44
32-13-42Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 11/4/13 01-13-42
09-13-42
27-13-42
33-13-41
02-13-37
11-13-37
30-13-37
03-13-37
14-13-38
31-13-47
08-13-40
24-13-39
32-13-37Ch. 1121 Prior Authorization of Leukotriene Modifiers—
Pharmacy Services11/4/13 01-13-48
09-13-48
27-13-48
33-13-47
02-13-43
11-13-43
30-13-43
03-13-43
14-13-44
31-13-53
08-13-46
24-13-45
32-13-43Ch. 1121 Prior Authorization of Angiotensin Modulator Combinations—Pharmacy Services 11/4/13 01-13-43
09-13-43
27-13-43
33-13-42
02-13-38
11-13-38
30-13-38
03-13-38
14-13-39
31-13-48
08-13-41
24-13-40
32-13-38Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 11/22/13 01-13-52
09-13-50
27-13-49
33-13-49
02-13-44
11-13-44
30-13-44
03-13-44
14-13-45
31-13-57
08-13-49
24-13-46
32-13-44Ch. 1121 Prior Authorization of Analgesics
Narcotic Long Acting Analgesics
Narcotic Short Acting and Cough and Cold Medications—Pharmacy Services11/22/13 01-13-55
09-13-53
27-13-52
33-13-52
02-13-47
11-13-47
30-13-47
03-13-47
14-13-48
31-13-60
08-13-52
24-13-49
32-13-47
Ch. 1121 Prior Authorization of Vecamyl (mecamylamine)—
Pharmacy Services11/22/13 01-13-54
09-13-52
27-13-51
33-13-51
02-13-46
11-13-46
30-13-46
03-13-46
14-13-47
31-13-59
08-13-51
24-13-48
32-13-46Ch. 1121 Prior Authorization of Lipotropics Other—Pharmacy Services 11/22/13 01-13-53
09-13-51
27-13-50
33-13-50
02-13-45
11-13-45
30-13-45
03-13-45
14-13-46
31-13-58
08-13-50
24-13-47
32-13-45Ch. 1101 CAQH CORE Federal Mandate: Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) 11/22/13 99-13-14 Ch. 1101 Presumptive Eligibility as Determined by Hospitals 12/6/13 01-13-56 Ch. 1121 Preferred Drug List (PDL) Update January 22, 2014—
Pharmacy Services12/18/13 01-13-57
02-13-48
03-13-48
08-13-53
09-13-54
11-13-48
14-13-49
24-13-50
27-13-53
30-13-48
31-13-61
32-13-48
33-13-53Ch. 1150 Medical Assistance Program Fee Schedule Revisions 12/27/13 99-13-13 2014 Ch. 1150 Additions to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent Flu Vaccine 08-14-02 1/7/14 01-14-03
09-14-01
31-14-02
33-14-01Ch. 1101 Changes to MA 112 Newborn Eligibility Form 1/10/14 01-14-02
47-14-01
Ch. 1101 Implementation of the CMS-1500 Health Insurance Claim Form (version 02-12) 1/10/14 99-14-03 Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 1/20/14 01-14-05
09-14-03
27-14-02
33-14-03
02-14-02
11-14-02
30-14-02
03-14-02
14-14-02
31-14-04
08-14-04
24-14-02
32-14-02Ch. 1121 Prior Authorization of Antipsoriatics Oral—Pharmacy Services 1/20/14 01-14-04
08-14-03
14-14-01
30-14-01
33-14-02
02-14-01
09-14-02
24-14-01
31-14-03
03-14-01
11-14-01
27-14-01
32-14-01Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 2/3/14 01-14-06
02-14-03
03-14-03
08-14-05
09-14-04
11-14-03
14-14-03
24-14-03
27-14-03
30-14-03
31-14-05
32-14-03
33-14-04Ch. 1121 Prior Authorization of Histamine II Receptor Blockers—Pharmacy Services 2/3/14 01-14-08
09-14-06
27-14-05
33-14-06
02-14-05
11-14-05
30-14-05
03-14-05
14-14-05
31-14-07
08-14-07
24-14-05
32-14-05Ch. 1121 Prior Authorization of Oncology Agents Oral—
Pharmacy Services2/3/14 01-14-11
09-14-09
27-14-08
33-14-09
02-14-08
11-14-08
30-14-08
03-14-08
14-14-08
31-14-10
08-14-10
24-14-08
32-14-08Ch. 1121 Prior Authorization of Epinephrine Self-Injected—
Pharmacy Services2/3/14 01-14-07
09-14-05
27-14-04
33-14-05
02-14-04
11-14-04
30-14-04
03-14-04
14-14-04
31-14-06
08-14-06
24-14-04
32-14-04Ch. 1121 Prior Authorization of Immunomodulators Topical—
Pharmacy Services2/3/14 01-14-09
09-14-07
27-14-06
33-14-07
02-14-06
11-14-06
30-14-06
03-14-06
14-14-06
31-14-08
08-14-08
24-14-06
32-14-06Ch. 1121 Prior Authorization of Iron Oral—Pharmacy Services 2/3/14 01-14-10
09-14-08
27-14-07
33-14-08
02-14-07
11-14-07
30-14-07
03-14-07
14-14-07
31-14-09
08-14-09
24-14-07
32-14-07Ch. 1121 Prior Authorization of Progestational Agents—
Pharmacy Services2/3/14 01-14-12
09-14-10
27-14-09
33-14-10
02-14-09
11-14-09
30-14-09
03-14-09
14-14-09
31-14-11
08-14-11
24-14-09
32-14-09Ch. 1150 Sample Review of Physicians Receiving Increased Fees for Select Primary Care Services 2/18/14 31-14-12
Ch. 1121 Specialty Pharmacy Drug Program—Updated List of Covered Drugs—Pharmacy Services 2/18/14 99-14-05 Ch. 1101 Provider Credentialing by the Pennsylvania Medical Assistance Program 2/27/14 99-14-02 Ch. 1101 Re-enrollment/Revalidation of Medical Assistance (MA) Providers 3/7/14 99-14-06 Ch. 1149 2014 Recommended Childhood and Adolescent Immunization Schedules 4/1/14 99-14-07 Ch. 1121 Prior Authorization of Prescriptions That Exceed Established Quantity Limits/Daily Dose Limits—Pharmacy Services 4/25/14 01-14-18
09-14-13
27-14-11
33-14-12
02-14-11
11-14-11
30-14-11
03-14-14
14-14-11
31-14-16
08-14-14
24-14-11
32-14-11Ch. 1121 Prior Authorization of Kalydeco (ivacaftor)—Pharmacy Services 4/25/14 01-14-17
02-14-10
03-14-13
08-14-13
09-14-12
11-14-10
14-14-10
24-14-10
27-14-10
30-14-10
31-14-15
32-14-10
33-14-11Ch. 1243 Addition to the Medical Assistance Program Fee Schedule—Oncotype DX 5/6/14 01-14-16
08-14-12
09-14-11
28-14-01
31-14-14Ch. 1121 Prior Authorization of Analgesics Narcotic Long Acting—Pharmacy Services 05/30/14 01-14-24
09-14-19
27-14-17
33-14-18
02-14-16
11-14-16
30-14-16
03-14-19
14-14-16
31-14-22
08-14-20
24-14-16
32-14-16Ch. 1121 Prior Authorization of Immune Globulins—Pharmacy Services 05/30/14 01-14-25
09-14-20
27-14-18
33-14-19
02-14-17
11-14-17
30-14-17
03-14-20
14-14-17
31-14-23
08-14-21
24-14-17
32-14-17Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 05/30/14 01-14-22
09-14-17
27-14-15
33-14-16
02-14-14
11-14-14
30-14-14
03-14-17
14-14-14
31-14-20
08-14-18
24-14-14
32-14-14Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Services 05/30/14 01-14-21
09-14-16
27-14-14
33-14-15
02-14-13
11-14-13
30-14-13
03-14-16
14-14-13
31-14-19
08-14-17
24-14-13
32-14-13Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and Type B)—Pharmacy Services 05/30/14 01-14-23
09-14-18
27-14-16
33-14-17
02-14-15
11-14-15
30-14-15
03-14-18
14-14-15
31-14-21
08-14-19
24-14-15
32-14-15Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 05/30/14 01-14-20
09-14-15
27-14-13
33-14-14
02-14-12
11-14-12
30-14-12
03-14-15
14-14-12
31-14-18
08-14-16
24-14-12
32-14-12
Ch. 1101 2014 HCPCS Updates and Other Procedure Code Changes 06/13/14 99-14-04 Ch. 1121 Preferred Drug List (PDL) Updated July 22, 2014—
Pharmacy Services07/07/14 01-14-26
09-14-21
27-14-19
33-14-20
02-14-18
11-14-18
30-14-18
03-14-21
14-14-18
31-14-24
08-14-22
24-14-18
32-14-18Ch. 1141
1150ACA Primary Care Services 2014 Fee Schedule 07/07/14 31-14-13 Ch. 1121 Prior Authorization of Hypoglycemic, Alpha-Glucosidase Inhibitors—Pharmacy Services 07/25/14 01-14-33
09-14-28
27-14-26
33-14-27
02-14-25
11-14-25
30-14-25
03-14-28
14-14-25
31-14-31
08-14-29
24-14-25
32-14-25Ch. 1121 Prior Authorization of Hypoglycemics, Metformins—
Pharmacy Services07/25/14 01-14-34
02-14-26
03-14-29
08-14-30
09-14-29
11-14-26
14-14-26
24-14-26
27-14-27
30-14-26
31-14-32
32-14-26
33-14-28Ch. 1121 Prior Authorization of Hypoglycemics, Sulfonylureas—
Pharmacy Services07/25/14 01-14-35
02-14-27
03-14-30
08-14-31
09-14-30
11-14-27
14-14-27
24-14-27
27-14-28
30-14-27
31-14-33
32-14-27
33-14-29Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services07/25/14 01-14-36
02-14-28
03-14-31
08-14-32
09-14-31
11-14-28
14-14-28
24-14-28
27-14-29
30-14-28
31-14-34
32-14-28
33-14-30
Ch. 1121 Prior Authorization of Antiparasitics, Topical—
Pharmacy Services07/25/14 01-14-31
09-14-26
27-14-24
33-14-25
02-14-23
11-14-23
30-14-23
03-14-26
14-14-23
31-14-29
08-14-27
24-14-23
32-14-23Ch. 1121 Prior Authorization of Antimigraine Agents, Other—
Pharmacy Services07/25/14 01-14-29
09-14-24
27-14-22
33-14-23
02-14-21
11-14-21
30-14-21
03-14-24
14-14-21
31-14-27
08-14-25
24-14-21
32-14-21Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 07/25/14 01-14-28
02-14-20
03-14-23
08-14-24
09-14-23
11-14-20
14-14-20
24-14-20
27-14-21
30-14-20
31-14-26
32-14-20
33-14-22Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 07/25/14 01-14-38
02-14-30
03-14-33
08-14-34
09-14-33
11-14-30
14-14-30
24-14-30
27-14-31
30-14-30
31-14-36
32-14-30
33-14-32Ch. 1121 Prior Authorization of Nitrofuran Derivatives—
Pharmacy Services07/25/14 01-14-37
02-14-29
03-14-32
08-14-33
09-14-32
11-14-29
14-14-29
24-14-29
27-14-30
30-14-29
31-14-35
32-14-29
33-14-31Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—Pharmacy Services 07/25/14 01-14-32
09-14-27
27-14-25
33-14-26
02-14-24
11-14-24
30-14-24
03-14-27
14-14-24
31-14-30
08-14-28
24-14-24
32-14-24Ch. 1121 Prior Authorization of Thyroid Hormones—Pharmacy Services 07/25/14 01-14-39
02-14-31
03-14-34
08-14-35
09-14-34
11-14-31
14-14-31
24-14-31
27-14-32
30-14-31
31-14-37
32-14-31
33-14-33Ch. 1121 Prior Authorization of Acne Agents, Oral—Pharmacy Services 08/05/14 01-14-27
09-14-22
27-14-20
33-14-21
02-14-19
11-14-19
30-14-19
03-14-22
14-14-19
31-14-25
08-14-23
24-14-19
32-14-19Ch. 1121 Prior Authorization of Ulcerative Colitis Agents—
Pharmacy Services08/05/14 01-14-40
09-14-35
27-14-33
33-14-34
02-14-32
11-14-32
30-14-32
03-14-35
14-14-32
31-14-38
08-14-36
24-14-32
32-14-32Ch. 1121 Prior Authorization of Antimigraine Agents, Triptans—
Pharmacy Services08/05/14 01-14-30
09-14-25
27-14-23
33-14-24
02-14-22
11-14-22
30-14-22
03-14-25
14-14-22
31-14-28
08-14-26
24-14-22
32-14-22Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 08/11/14 01-14-41
09-14-36
27-14-34
33-14-35
02-14-33
11-14-33
30-14-33
03-14-36
14-14-33
31-14-39
08-14-37
24-14-33
32-14-33Ch. 1101 Implementation of National Correct Coding Initiative Related Modifiers 09/12/14 99-14-08 Ch. 1149
1150New Procedure Code for Dental Services 09/27/14 27-14-12 Ch. 1101
1150Presumptive Eligibility for Pregnant Women 10-24-14 01-14-19
08-14-15
09-14-14
31-14-17
33-14-13
47-14-02Ch. 1101 Implementation of Healthy Pennsylvania 11/04/14 99-14-09 Ch. 1101
1141
1150
1221Advanced Radiologic Imaging Services 11/21/14 01-14-42 Ch. 1123 Revisions to Prior Authorization Requirements For Apnea Monitors 12/09/14 24-14-34
25-14-01Ch. 1101 Healthy PA Benefit Plans 12/12/14 99-14-10 Ch. 1141
1150Medical Assistance Fees for Primary Care Services 12/20/14 31-14-40 Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/29/14 01-14-53
02-14-43
03-14-46
08-14-47
09-14-46
11-14-43
14-14-43
24-14-44
27-14-44
30-14-43
31-14-50
32-14-43
33-14-45
Ch. 1121 Prior Authorization of Anti-Allergens, Oral—Pharmacy Services 12/29/14 01-14-47
09-14-40
27-14-38
33-14-39
02-14-37
11-14-37
30-14-37
03-14-40
14-14-37
31-14-44
08-14-41
24-14-38
32-14-37Ch. 1121 Prior Authorization of Rilutek (riluzole)—Pharmacy Services 12/29/14 01-14-51
02-14-41
03-14-44
08-14-45
09-14-44
11-14-41
14-14-41
24-14-42
27-14-42
30-14-41
31-14-48
32-14-41
33-14-43Ch. 1121 Prior Authorization of Compounded Prescriptions—
Pharmacy Services12/29/14 01-14-44
02-14-34
03-14-37
08-14-38
09-14-37
11-14-34
14-14-34
24-14-35
27-14-35
30-14-34
31-14-41
32-14-34
33-14-36Ch. 1121 Prior Authorization of Cytokine And CAM Antagonists—Pharmacy Services 12/29/14 01-14-52
02-14-42
03-14-45
08-14-46
09-14-45
11-14-42
14-14-42
24-14-43
27-14-43
30-14-42
31-14-49
32-14-42
33-14-44Ch. 1121 Prior Authorization of Soliris (eculizumab)—Pharmacy Services 12/29/14 01-14-48
09-14-41
27-14-39
33-14-40
02-14-38
11-14-38
30-14-38
03-14-41
14-14-38
31-14-45
08-14-42
24-14-39
32-14-38Ch. 1121 Prior Authorization of Mozobil (Plerixafor)—Pharmacy Services 12/29/14 01-14-49
09-14-42
27-14-40
33-14-41
02-14-39
11-14-39
30-14-39
03-14-42
14-14-39
31-14-46
08-14-43
24-14-40
32-14-39Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—
Pharmacy Services12/29/14 01-14-50
02-14-40
03-14-43
08-14-44
09-14-43
11-14-40
14-14-40
24-14-41
27-14-41
30-14-40
31-14-47
32-14-40
33-14-42Ch. 1121 Prior Authorization of Xolair—Pharmacy Services 12/29/14 01-14-45
02-14-35
03-14-38
08-14-39
09-14-38
11-14-35
14-14-35
24-14-36
27-14-36
30-14-35
31-14-42
32-14-35
33-14-37Ch. 1121 Prior Authorization of Ranexa (ranolazine)—Pharmacy Services 12/29/14 01-14-46
02-14-36
03-14-39
08-14-40
09-14-39
11-14-36
14-14-36
24-14-37
27-14-37
30-14-36
31-14-43
32-14-36
33-14-38Ch. 1150
1245Non-Payment of Unloaded Ground or Air Ambulance Mileage 12/30/14 26-14-01 2015 Ch. 1101 Healthy PA Interim Benefit Plan 01/14/15 99-15-02 Ch. 1130 Hospice Services 01/19/15 06-15-01
09-14-47
31-14-51Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 02/04/15 01-15-04
02-15-03
03-15-03
08-15-04
09-15-04
11-15-03
14-15-03
24-15-03
27-15-03
30-15-03
31-15-04
32-15-03
33-15-04Ch. 1121 Prior Authorization of Thalidomide And Derivatives—
Pharmacy Services02/04/15 01-15-06
02-15-05
03-15-05
08-15-06
09-15-06
11-15-05
14-15-05
24-15-05
27-15-05
30-15-05
31-15-06
32-15-05
33-15-06Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 02/04/15 01-15-03
02-15-02
03-15-02
08-15-03
09-15-03
11-15-02
14-15-02
24-15-02
27-15-02
30-15-02
31-15-03
32-15-02
33-15-03Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 02/04/15 01-15-05
02-15-04
03-15-04
08-15-05
09-15-05
11-15-04
04-15-04
24-15-04
27-15-04
30-15-04
31-15-05
32-15-04
33-15-05Ch. 1121 Addition to the Medical Assistance Program Fee Schedule for Administration Of Quadrivalent—
Influenza Vaccine02/18/15 01-15-01
08-15-01
09-15-01
31-15-01
33-15-01Ch. 1121 Preferred Drug List (PDL) Update January 21, 2015—
Pharmacy Services02/18/15 01-15-02
09-15-02
27-15-01
33-15-02
02-15-01
11-15-01
30-15-01
03-15-01
14-15-01
31-15-02
08-15-02
24-15-01
32-15-01Ch. 1163 Revised Presumptive Eligibility As Determined by Hospitals 02/24/15 01-15-08 Ch. 1101 Medical Assistance Program Fee Schedule Revisions 03/02/15 99-15-01* Ch. 1101 Medical Assistance Program Fee 03/17/15 99-15-03 Ch. 1101
1150
1225Payment Increase for the Title XIX Medical Assistance Program Family Planning Clinics that Dispense Oral Contraceptives 03/23/15 08-15-08 Ch. 1241 2015 Recommended Childhood and Adolescent Immunization Schedules 03/23/15 99-15-04 Ch. 1150
1245Non-Payment of Unloaded Ground or Air Ambulance Mileage 03/23/15 26-15-01 Ch. 1121 Implementation of HealthChoices Medicaid Expansion 04/28/15 99-15-05 Ch. 1121 Prior Authorization of Idiopathic Fibrosis Agent—
Pharmacy Service05/11/15 01-15-14
02-15-12
03-15-12
08-15-14
09-15-13
11-15-12
14-15-12
24-15-12
27-15-12
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Hypoglycemics, Insulin—
Pharmacy Services05/11/15 01-15-10
02-15-08
03-15-08
08-15-10
09-15-09
11-15-08
14-15-08
24-15-08
27-15-08
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Intra-Articular Hyaluronic Acid Agents—Pharmacy Service 05/11/15 01-15-12
02-15-10
03-15-10
08-15-12
09-15-11
11-15-10
14-15-10
24-15-10
27-15-10
30-15-10
31-15-11
32-15-10
33-15-11Ch. 1121 Prior Authorization of Santyl Ointment (collagenase)—
Pharmacy Service05/11/15 01-15-13
02-15-11
03-15-11
08-15-13
09-15-12
11-15-11
14-15-11
24-15-11
27-15-11
30-15-11
31-15-12
32-15-11
33-15-12Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services05/11/15 01-15-09
02-15-07
03-15-07
08-15-09
09-15-08
11-15-07
14-15-07
24-15-07
27-15-07
30-15-07
31-15-08
32-15-07
33-15-08Ch. 1121 Prior Authorization of Antifungals, Topical—Pharmacy Services 06/22/15 01-15-17
02-15-14
03-15-14
08-15-17
09-15-17
11-15-14
14-15-14
24-15-15
27-15-14
30-15-14
31-15-17
32-15-14
33-15-16Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 06/22/15 01-15-16
02-15-13
03-15-13
08-15-16
09-15-16
11-15-13
14-15-13
24-15-14
27-15-13
30-15-13
31-15-16
32-15-13
33-15-15Ch. 1121 Prior Authorization of GI Motility, Chronic Agents (Formerly Irritable Bowel Syndrome Agents)—
Pharmacy Services06/25/15 01-15-18
02-15-15
03-15-15
08-15-18
09-15-18
11-15-15
14-15-15
24-15-16
27-15-15
30-15-15
31-15-18
32-15-15
33-15-17Ch. 1121 Preferred Drug List (PDL) Update July 20, 2015—
Pharmacy Services06/25/15 01-15-23
02-15-20
03-15-20
08-15-23
09-15-23
11-15-20
14-15-20
24-15-21
27-15-20
30-15-20
31-15-23
32-15-20
33-15-22Ch. 1121 Prior Authorization of Platelet Aggregation Inhibitors—Pharmacy Services 06/25/15 01-15-20
02-15-17
03-15-17
08-15-20
09-15-20
11-15-17
14-15-17
24-15-18
27-15-17
30-15-17
31-15-20
32-15-17
33-15-19Ch. 1121 Prior Authorization of Contraceptives, Other—
Pharmacy Services06/25/15 01-15-19
02-15-16
03-15-16
08-15-19
09-15-19
11-15-16
14-15-16
24-15-17
27-15-16
30-15-16
31-15-19
32-15-16
33-15-18Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 06/25/15 01-15-22
02-15-19
03-15-19
08-15-22
09-15-22
11-15-19
14-15-19
24-15-20
27-15-19
30-15-19
31-15-22
32-15-19
33-15-21Ch. 1127
1141
1221
1225Family Planning Services 6/29/15 01-15-15
08-15-15
09-15-15
24-15-13
25-15-01
28-15-01
31-15-15
33-15-14Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Service 06/30/15 01-15-21
02-15-18
03-15-18
08-15-21
09-15-21
11-15-18
14-15-18
24-15-19
27-15-18
30-15-18
31-15-21
32-15-18
33-15-20Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Service 07/13/15 01-15-11
02-15-09
03-15-09
08-15-11
09-15-10
11-15-09
14-15-09
24-15-09
27-15-09
30-15-09
31-15-10
32-15-09
33-15-10Ch. 1121 Preferred Drug List (PDL) Update July 20, 2015 Corrections—Pharmacy Services 08/07/15 01-15-26
02-15-23
03-15-23
08-15-26
09-15-26
11-15-23
14-15-23
24-15-24
27-15-23
30-15-23
31-15-26
32-15-23
33-15-25Ch. 1241 Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 08/10/15 99-15-07 Ch. 1101
1150Addition to the Medical Assistance Program Fee Schedule for Administration of HPV 9 Vaccine 08/31/15 01-15-29
08-15-29
09-15-29
31-15-29
33-15-28Ch. 1101
1150Prior Authorization Requirements and Fee Schedule Updates for Hyperbaric Oxygen Therapy 08/31/15 01-15-30
14-15-25
31-15-30Ch. 1101
11502015 HCPCS Updates and Other Procedure Codes 08/31/15 99-15-06 Ch. 1101
1150Procedure Code Changes for Application of Topical Fluoride Varnish by Physicians and CRNPs 09/01/15 09-15-14
31-15-14
Ch. 1126
1129
1151
1181
1187
1189Provider Preventable Conditions 09/01/15 01-15-28
03-15-24
09-15-28
18-15-02
31-15-28
33-15-27
02-15-24
08-15-28
14-15-24
27-15-24
32-15-24
47-15-01Ch. 1121 Specialty Pharmacy Drug Program—Pharmacy Services 08/20/15 99-15-08 Ch. 1101
1150Medical Assistance (MA) Program's Implementation of ICD-10 Diagnosis and Procedure Code Sets 08/28/15 99-15-09 Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Service 09/04/15 01-15-24
09-15-24
27-15-21
02-15-21
11-15-21
30-15-21
03-15-21
14-15-21
31-15-24
08-15-24
24-15-22
32-15-21
33-15-23Ch. 1121 Prior Authorization of Opiate Dependence Treatments, Oral Buprenorphine Agents—Pharmacy Service 09/04/15 01-15-25
09-15-25
27-15-22
02-15-22
11-15-22
30-15-22
03-15-22
14-15-22
31-15-25
08-15-25
24-15-23
32-15-22
33-15-24Ch. 1241 Implementation of ICD-10 Diagnosis Sets for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screens 09/14/15 99-15-11 Ch. 1101
1150New Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Application for Benefits and Updated ICD-10 Codes 09/21/15 99-15-10 Ch. 1121 Trumenba and Bexsero Meningococcal B Vaccines 10/26/15 01-15-31
08-15-30
09-15-30
31-15-31
33-15-29Ch. 1121 Prior Authorization of Kalydeco, Nuedexta and Xyrem—Pharmacy Service 11/10/15 01-15-37
02-15-29
03-15-29
08-15-35
09-15-35
11-15-28
14-15-30
24-15-30
27-15-29
30-15-28
31-15-36
32-15-29
33-15-34
Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 11/13/15 01-15-33
02-15-25
03-15-25
08-15-31
09-15-31
11-15-24
14-15-26
24-15-26
27-15-25
30-15-24
31-15-32
32-15-25
33-15-30Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—
Pharmacy Service11/13/15 01-15-35
02-15-27
03-15-27
08-15-33
09-15-33
11-15-26
14-15-28
24-15-28
27-15-27
30-15-26
31-15-34
32-15-27
33-15-32Ch. 1121 Prior Authorization of Antibiotics, GI—Pharmacy Service 11/13/15 01-15-36
02-15-28
03-15-28
08-15-34
09-15-34
11-15-27
14-15-29
24-15-29
27-15-28
30-15-27
31-15-35
32-15-28
33-15-33Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Service11/18/15 01-15-34
02-15-26
03-15-26
08-15-32
09-15-32
11-15-25
14-15-27
24-15-27
27-15-26
30-15-25
31-15-33
32-15-26
33-15-31Ch. 1163 Revised Procedures for Presumptive Eligibility as Determined by Hospitals 11/30/15 01-15-32 Ch. 1121 Prior Authorization of Corlanor (ivabradine)—
Pharmacy Service11/30/15 01-15-39
09-15-37
27-15-31
02-15-31
11-15-30
30-15-30
03-15-31
14-15-32
31-15-38
08-15-37
24-15-32
32-15-31
33-15-36Ch. 1121 Prior Authorization of Alpha-1 Proteinase Inhibitors—
Pharmacy Service11/30/15 01-15-38
09-15-36
27-15-30
02-15-30
11-15-29
30-15-29
03-15-30
14-15-31
31-15-37
08-15-36
24-15-31
32-15-30
33-15-35Ch. 1127
1141
1221
1225Implementation of ICD-10 Diagnosis Codes for the Family Planning Services Program 11/30/15 01-15-27
08-15-27
09-15-27
24-15-25
25-15-02
28-15-02
31-15-27
33-15-26Ch. 1121 Prior Authorization of Orkambi (lumacaftor/ivacaftor)—Pharmacy Service 11/30/15 01-15-40
09-15-38
27-15-32
02-15-32
11-15-31
30-15-31
03-15-32
14-15-33
31-15-39
08-15-38
24-15-33
32-15-32
33-15-37Ch. 1101
1150The Addition of Three-Dimensional (3D) Mammography Procedure Codes to the Medical Assistance Program Fee Schedule 12/09/15 01-15-41
08-15-39
09-15-39
31-15-40Ch. 1130
1249Hospice Two-Tiered Routine Home Care and Service Intensity Add-On Payments 12/31/15 06-15-02
09-15-40
31-15-41Ch. 1121 Preferred Drug List (PDL) Update January 20, 2016— Pharmacy Services 01/08/16 01-16-01
09-16-01
27-16-01
02-16-01
11-16-01
30-16-01
03-16-01
14-16-01
31-16-01
08-16-01
24-16-01
32-16-01
33-16-01Ch. 1121 Prior Authorization of Bile Salts—Pharmacy Service 01/06/16 01-16-02
09-16-02
27-16-02
02-16-02
11-16-02
30-16-02
03-16-02
14-16-02
31-16-02
08-16-02
24-26-02
32-16-02
33-16-02Ch. 1121 Prior Authorization of Methotrexate—Pharmacy Service 01/06/16 01-16-06
09-16-06
27-16-06
02-16-06
11-16-06
30-16-06
03-16-06
14-16-06
31-16-06
08-16-06
24-16-06
32-16-06
33-16-06Ch. 1121 Prior Authorization of Macular Degeneration Agents—Pharmacy Service 01/06/16 01-16-04
09-16-04
27-16-04
02-16-04
11-16-04
30-16-04
03-16-04
14-16-04
31-16-04
08-16-04
24-16-04
32-16-04
33-16-04
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