[48 Pa.B. 5943]
[Saturday, September 22, 2018]
[Continued from previous Web Page]
Year Code Citation(s) Subject Date Issued Bulletin
NumberCh. 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 Services4/25/14 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
32-14-12Ch. 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
33-14-30Ch. 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
33-14-45Ch. 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 Services 12/29/14 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 Service 05/11/15 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
31-15-30
Ch. 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 33-15-29 Ch. 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 33-15-30 Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—Pharmacy Service 11/13/15 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 33-15-32 Ch. 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 33-15-33 Ch. 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 33-15-31 Ch. 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 33-15-36 Ch. 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 33-15-35 Ch. 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 33-15-26 Ch. 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 33-15-37 Ch. 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 31-15-40 Ch. 1130
1249Hospice Two-Tiered Routine Home Care and Service Intensity Add-On Payments 12/31/15 06-15-02 09-15-40 31-15-41 Ch. 1121 Preferred Drug List (PDL) Update January 20, 2016—
Pharmacy Services01/08/16 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 33-16-01 Ch. 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 33-16-02 Ch. 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 33-16-06 Ch. 1121 Prior Authorization of Macular Degeneration Agents—
Pharmacy Service01/06/16 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 Ch. 1121 Prior Authorization of COPD Agents—Pharmacy Service 01/06/16 01-16-03 09-16-03 27-16-03 02-16-03 11-16-03 30-16-03 03-16-03 14-16-03 31-16-03 08-16-03 24-16-03 32-16-03 33-16-03 Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Service 01/06/16 01-16-08 09-16-08 27-16-08 02-16-08 11-16-08 30-16-08 03-16-08 14-16-08 31-16-08 08-16-08 24-16-08 32-16-08 33-16-08 Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Service 01/06/16 01-16-05 09-16-05 27-16-05 02-16-05 11-16-05 30-16-05 03-16-05 14-16-05 31-16-05 08-16-05 24-16-05 32-16-05 33-16-05 Ch. 1149 Required Training for the Application of Topical Fluoride Varnish 02/26/16 09-16-10 31-16-10 Ch. 1249 Updates to the Medical Assistance Program Fee Schedule for HHA Nursing Visits 03/10/16 05-06-01 Ch. 1121 Prior Authorization of Anticonvulsants, Oral; Duloxetine Agents; and Neuropathic Pain Agents— Pharmacy Service 03/14/16 01-16-09 09-16-11 27-16-09 02-16-09 11-16-09 30-16-09 03-16-09 14-16-09 31-16-11 08-16-09 24-16-10 32-16-09 Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Service 03-14-16 01-16-11 09-16-13 27-16-11 02-16-11 11-16-11 30-16-11 03-16-11 14-16-11 31-16-13 08-16-11 24-16-12 32-16-11 33-16-11 Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Service 03/14/16 01-16-10 09-16-12 27-16-10 02-16-10 11-16-10 30-16-10 03-16-10 14-16-10 31-16-12 08-16-10 24-16-11 32-16-10 33-16-10 Ch. 1140 Updates to the Medical Assistance Program Fee Schedule For Healthy Beginnings Plus 03/18/16 01-16-12 05-16-02 08-16-12 31-16-14 33-16-12 47-16-01 Ch. 1101 Enrollment of Ordering, Referring and Prescribing Providers 04/01/16 99-16-07 Ch. 1150 Procedure for Obtaining an 1150 Administrative Waiver for Durable Medical Equipment, Medical Supplies or Prosthetics and Orthotics 04/19/16 09-16-09 24-16-09 25-16-01 31-16-09 Ch. 1101 Revalidation of Medical Assistance (MA) Providers 05/26/16 99-16-10 Ch. 1101 Enrollment of Co-Located Providers 05/31/16 99-16-04 Ch. 1121 Prior Authorization of Provenge (sipuleucel-T)—
Pharmacy Service06/13/16 01-16-17 09-16-16 27-16-15 02-16-15 11-16-115 30-16-15 03-16-15 14-16-15 31-16-18 08-16-16 24-16-16 32-16-14 33-16-15 Ch. 1121 Prior Authorization of Antihyperuricemics—Pharmacy Service 06/13/16 01-16-15 09-16-14 27-16-13 02-16-13 11-16-13 30-16-13 03-16-13 14-16-13 31-16-16 08-16-14 24-16-14 32-16-12 33-16-13
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