[49 Pa.B. 4391]
[Saturday, August 10, 2019]
[Continued from previous Web Page]
Ch. 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
33-15-23
Ch. 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
33-15-24
Ch. 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 Service 11/18/15 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 Service 11/30/15 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 Service 11/30/15 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
31-15-41Ch. 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
33-16-02
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 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
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
33-16-08Ch. 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
33-16-11Ch. 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 Service 06/13/16 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
Ch. 1121 Prior Authorization of Xofigo (radium Ra 223 dichloride)—Pharmacy Service 06/13/16 01-16-18
09-16-17
27-16-16
02-16-16
11-16-16
30-16-16
14-16-16
31-16-19
08-16-17
24-16-17
32-16-15
33-16-16
Ch. 1123 Ch. 1249 Face-to-Face Encounter Requirements for Prescribing of Home Health Services Including Durable Medical Equipment and Medical Supplies 06/27/16 05-16-04 24-16-18 25-16-03 31-16-21 Ch. 1101 2016 Healthcare Common Procedure Coding System (HCPCS) Updates and Other Procedure Code Changes 06/27/16 99-16-08 Ch. 1150 Observation Services 06/27/16 01-16-19 14-16-17 27-16-17 31-16-20 Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—Pharmacy Services 07/05/16 01-16-22
09-16-20
27-16-20
02-16-19
11-16-19
30-16-19
03-16-19
14-16-20
31-16-24
08-16-20
24-16-22
32-16-18
33-16-19
Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 07/05/16 01-16-20
09-16-18
27-16-18
02-16-17
11-16-17
30-16-17
03-16-18
14-16-18
31-16-22
08-16-18
24-16-20
32-16-16
33-16-17
Ch. 1121 Prior Authorization of Cephalosporins and Related Agents—Pharmacy Services 07/05/16 01-16-28
09-16-26
27-16-26
02-16-25
11-16-25
30-16-25
03-16-25
14-16-26
31-16-30
08-16-26
24-16-28
32-16-24
33-16-25
Ch. 1121 Preferred Drug List (PDL) Update July 18, 2016—Pharmacy Services 07/05/16 01-16-26
09-16-24
27-16-24
02-16-23
11-16-23
30-16-23
03-16-23
14-16-24
31-16-28
08-16-24
24-16-26
32-16-22
33-16-23
Ch. 1121 Prior Authorization of Antifungals, Topical—Pharmacy Services 07/05/16 01-16-21
09-16-19
27-16-19
02-16-18
11-16-18
30-16-18
03-16-18
14-16-19
31-16-23
08-16-19
24-16-21
32-16-17
33-16-18
Ch. 1121 Prior Authorization of Tetracyclines—Pharmacy Services 07/05/16 01-16-25
09-16-23
27-16-23
02-16-22
11-16-22
30-16-22
03-16-22
14-16-23
31-16-27
08-16-23
24-16-25
32-16-21
33-16-22
Ch. 1121 Prior Authorization of Opiate Overdose Agents—Pharmacy Services 07/07/16 01-16-27
09-16-25
27-16-25
02-16-24
11-16-24
30-16-24
03-16-24
14-16-25
31-16-29
08-16-25
24-16-24
32-16-23
33-16-24
Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 07/08/16 01-16-24
02-16-21
03-16-21
08-16-22
09-16-22
11-16-21
14-16-22
24-16-24
27-16-22
30-16-21
31-16-26
32-16-20
33-16-21
Ch. 1101 Federal Final Rule, ''Nondiscrimination in Health Programs and Activities'' and Implication for Coverage of Services Related Gender Transition 07/18/16 99-16-11 Ch. 1121 Coverage for Mosquito Repellants 07/18/16 99-16-14 Ch. 1101 Enrollment of Physician Assistants Who Order, Refer and Prescribe for Medical Assistance Beneficiaries 08/03/16 10-16-01 Ch. 1101 Assignment of ACA Categorical Risk Levels and Implementation of Site Visits 08/04/16 99-16-13 Ch. 1101 Electronic Provider Enrollment Application 08/08/16 99-16-12 Ch. 1150 Payment of Claims for Services Provided to Children and Adolescents for the Diagnostic Assessment and Treatment of Autism Spectrum Disorder 08/17/16 99-16-15 Ch. 1150
1249Medical Assistance Program Fee Increases For Private Duty/Shift Nursing Services to MA Beneficiaries Under 21 Years of Age 08/26/16 05-16-05 16-16-01 Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 09/30/16 01-16-30
09-16-28
27-16-27
02-16-26
11-16-26
30-16-26
03-16-26
14-16-27
31-16-32
08-16-28
24-16-29
32-16-25
33-16-27
Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Service 10/20/16 01-16-31
09-16-29
27-16-28
02-16-27
11-16-27
30-16-27
03-16-27
14-16-28
31-16-33
08-16-29
24-16-30
32-16-26
33-16-28
Ch. 1101 Services Ordered, Referred, or Prescribed By Graduate Medical or Osteopathic Trainees 11/02/16 01-16-32 31-16-34 Ch. 1101
1225MA Program Fee Schedule Updates for Certain Family Planning Services 11/26/16 01-16-33 08-16-31 09-16-30 28-16-02 31-16-35 33-16-29 Ch. 1101
1150
1121Federally Qualified Health Center Alternative Payment Methodologies for Delivery Services 11/28/16 08-16-30 Ch. 1121 Addition to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent Flu Vaccine Derived from Cell Cultures 12/23/16 01-17-01 08-17-01 09-17-01 31-17-01 33-17-01 Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Service 01/04/17 01-17-02
02-17-01
03-17-01
08-17-02
09-17-02
11-17-01
14-17-01
24-17-01
27-17-01
30-17-02
31-17-03
32-17-01
33-17-02Ch. 1101
1150Submission of Claims that Require the National Provider Identifier (NPI) of the Ordering, Referring or Prescribing Provider 01/30/17 99-17-02 Ch. 1121 Prior Authorization of Anitparkinson's Agents—Pharmacy Services 01/30/17 01-17-06
09-17-05
27-17-04
02-17-04
11-17-04
30-17-05
03-17-04
14-17-04
31-17-06
08-17-05
24-17-04
32-17-04
33-17-05
Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 01/30/17 01-17-09
09-17-08
27-17-07
02-17-07
11-17-07
30-17-08
03-17-07
14-17-07
31-17-09
08-17-08
24-17-07
32-17-07
33-17-08
Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—Pharmacy Services 01/30/17 01-17-10
09-17-09
27-17-08
02-17-08
11-17-08
30-17-09
03-17-08
14-17-08
31-17-10
08-17-09
24-17-08
32-17-08
33-17-09Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 01/30/17 01-17-11
02-17-09
03-17-09
08-17-10
09-17-10
11-17-09
14-17-09
24-17-09
27-17-09
30-17-10
31-17-11
32-17-09
33-17-10Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Service 01/31/17 01-17-04
09-17-03
27-17-02
02-17-02
11-17-02
30-17-03
03-17-02
14-17-02
31-17-04
08-17-03
24-17-02
32-17-02
33-17-03
Ch. 1121 Prior Authorization of Analgesics, Non-Narcotic Barbiturate Combinations—Pharmacy Service 01/31/17 01-17-05
09-17-04
27-17-03
02-17-03
11-17-03
30-17-04
03-17-03
14-17-03
31-17-05
08-17-04
24-17-03
32-17-03
33-17-04Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 01/31/17 01-17-07
09-17-06
27-17-05
02-17-05
11-17-05
30-17-06
03-17-05
14-17-05
31-17-07
08-17-06
24-17-05
32-17-05
33-17-06
Ch. 1121 Prior Authorization of Bile Salts—Pharmacy Service 01/31/17 01-17-08
09-17-07
27-17-06
02-17-06
11-17-06
30-17-07
03-17-06
14-17-06
31-17-08
08-17-07
24-17-06
32-17-06
33-17-07Ch. 1121 Prior Authorization of Nplate (romiplostim)—Pharmacy Services 01/31/17 01-17-12
02-17-10
03-17-10
08-17-11
09-17-11
11-17-10
14-17-10
24-17-10
27-17-10
30-17-11
31-17-12
32-17-10
33-17-11Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—Pharmacy Services 01/31/17 01-17-13
02-17-11
03-17-11
08-17-12
09-17-12
11-17-11
14-17-11
24-17-11
27-17-11
30-17-12
31-17-13
32-17-11
33-17-12Ch. 1121 Prior Authorization of Promacta (eltrombopag)—Pharmacy Services 01/31/17 01-17-14
02-17-12
03-17-12
08-17-13
09-17-13
11-17-12
14-17-12
24-17-12
27-17-12
30-17-13
31-17-14
32-17-12
33-17-13Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 01/31/17 01-17-15
02-17-13
03-17-13
08-17-14
09-17-14
11-17-13
14-17-13
24-17-13
27-17-13
30-17-14
31-17-15
32-17-13
33-17-14
Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Services 01/31/17 01-17-16
02-17-14
03-17-14
08-17-15
09-17-15
11-17-14
14-17-14
24-17-14
27-17-14
30-17-15
31-17-16
32-17-14
33-17-15
Ch. 1121 Prior Authorization of Xyrem (sodium oxybate)—Pharmacy Services 01/31/17 01-17-17
02-17-15
03-17-15
08-17-16
09-17-16
11-17-15
14-17-15
24-17-15
27-17-15
30-17-16
31-17-17
32-17-15
33-17-16
Ch. 1101 School-Based ACCESS Program Provider Handbook 02/28/17 35-17-01 Ch. 1101 Implementation of Criminal Background Checks for Providers Assigned ACA Categorical Risk Level of High 03/06/17 99-17-03 Ch. 1241 2017 Recommended Childhood and Adolescent Immunization Schedules 04/24/17 99-17-04 Ch. 1121 Prior Authorization of Xolair (omalizumab)—Pharmacy Services 04/27/17 01-17-18
02-17-16
03-17-16
08-17-18
09-17-17
11-17-16
14-17-16
24-17-16
27-17-16
30-17-17
31-17-18
32-17-16
33-17-17Ch. 1121 Prior Authorization of Ophthalmic Immunomodulators—Pharmacy Services 04/27/17 01-17-19
02-17-17
03-17-17
08-17-19
09-17-18
11-17-17
14-17-17
24-17-17
27-17-17
30-17-18
31-17-19
32-17-17
33-17-18Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services04/27/17 01-17-21
02-17-19
03-17-19
08-17-21
09-17-20
11-17-19
14-17-19
24-17-19
27-17-19
30-17-20
31-17-21
32-17-19
33-17-20Ch. 1129 Opt-In Procedures for Federally Qualified Health Centers and Rural Health Clinics to Receive the Prospective Payment System Rate from Managed Care Organizations 05/30/17 07-17-01 08-17-22 Ch. 1101 Discontinuance of Federally Qualified Health Center Alternative Payment Methodology for Delivery Services in the Federally Qualified Health Center Setting 05/30/17 08/17/17 Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Services 06/07/17 01-17-22
02-17-20
03-17-20
08-17-23
09-17-21
11-17-20
14-17-20
24-17-20
27-17-20
30-17-21
31-17-22
32-17-20
33-17-21
Ch. 1121 Prior Authorization of Cinqair (reslizumab)—Pharmacy Services 06/07/17 01-17-23
02-17-21
03-17-21
08-17-24
09-17-22
11-17-21
14-17-21
24-17-21
27-17-21
30-17-22
31-17-23
32-17-21
33-17-22
Ch. 1121 Prior Authorization of Exondys 51 (eteplirsen)—
Pharmacy Services06/07/17 01-17-24
02-17-22
03-17-22
08-17-25
09-17-23
11-17-22
14-17-22
24-17-22
27-17-22
30-17-23
31-17-24
32-17-22
33-17-23
Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services06/07/17 01-17-25
09-17-24
27-17-23
02-17-23
11-17-23
30-17-24
03-17-23
14-17-23
31-17-25
08-17-26
24-17-23
32-17-23
33-17-24
Ch. 1121 Prior Authorization of Oncology Agents, Breast Cancer—Pharmacy Services 06/07/17 01-17-26
02-17-24
03-17-24
08-17-27
09-17-25
11-17-24
14-17-24
24-17-24
27-17-24
30-17-25
31-17-26
32-17-24
33-17-25Ch. 1121 Prior Authorization of Spinraza (nusinersen)—
Pharmacy Services06/07/17 01-17-27
02-17-25
03-17-25
08-17-28
09-17-26
11-17-25
14-17-25
24-17-25
27-17-25
30-17-26
31-17-27
32-17-25
33-17-26Ch. 1101 Updates to the Medical Assistance Copayment Desk Reference 06/26/17 99-17-06 Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 06/28/17 01-17-30
02-17-26
03-17-26
08-17-32
09-17-28
11-17-26
14-17-26
24-17-27
27-17-27
30-17-27
31-17-30
32-17-26
33-17-29
Ch. 1121 Payment for Covered Outpatient Drugs—Pharmacy Services 06/28/17 99-17-09 Ch. 1121 Prior Authorization of Angiotensin Modulators—Pharmacy Services 07/13/17 01-17-34
09-17-32
27-17-30
02-17-29
11-17-29
30-17-30
03-17-29
14-17-29
31-17-34
08-17-35
24-17-30
32-17-29
33-17-33
Ch. 1121 Preferred Drug List (PDL) Update July 25, 2017—Pharmacy Services 07/21/17 01-17-32
02-17-27
03-17-27
08-17-33
09-17-30
11-17-27
14-17-27
24-17-27
27-17-28
30-17-28
31-17-32
32-17-27
33-17-31
Ch. 1149 Public Health Dental Hygiene Practitioner Enrollment in the Medical Assistance Program 08/01/17 08-17-31 10-17-01 27-17-26 Ch. 1241 Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 08/07/17 99-17-10 Ch. 1101
11502017 Healthcare Common Procedure Coding System (HCPCS) Updates and Other Procedure Code Changes 08/07/17 99-17-08 Ch. 1101
1150Pasteurized Donor Human Milk 08/07/17 01-17-31 09-17-29 25-17-02 31-17-31 33-17-30 Ch. 1101
1150
1225MA Program Fee Schedule Updates for Certain Family Planning Services 08/07/17 01-17-29 08-17-29 09-17-27 24-17-26 25-17-01 28-17-01 31-17-28 33-17-27 Ch. 1101
1150Procedure Code Change for Tobacco Cessation Counseling Services 08/07/17 99-17-07 Ch. 1121 Prior Authorization of Intra-Articular Hyaluronates—Pharmacy Services 08/08/17 01-17-33
02-17-28
03-17-28
08-17-34
09-17-31
11-17-28
14-17-28
24-17-29
27-17-29
30-17-29
31-17-33
32-17-28
33-17-32
Ch. 1127
1143
1163''Newborn Add'' Feature for COMPASS 08/09/17 01-17-28 33-17-28 47-17-01 Ch. 1101 Limited English Proficiency Requirements 08/11/17 99-17-11 Ch. 1101 School-Based ACCESS Program Provider Handbook 11/22/17 35-17-02 Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—Pharmacy Services 12/14/17 01-17-35
02-17-30
03-17-30
08-17-37
09-17-34
11-17-30
14-17-31
24-17-31
27-17-32
30-17-31
31-17-36
32-17-30
33-17-35
Ch. 1121 Prior Authorization of Analgesics, Opioid Long Acting—Pharmacy Services 12/27/17 01-17-36
02-17-31
03-17-31
08-17-37
09-17-35
11-17-31
14-17-32
24-17-32
27-17-33
30-17-32
31-17-37
32-17-31
33-17-36Ch. 1121 Prior Authorization of Xermelo (telotristat ethyl)—
Pharmacy Services12/27/17 01-17-44
02-17-39
03-17-39
08-17-46 09-17-43
11-17-39
14-17-40
24-17-40
27-17-41
30-17-40
31-17-45
32-17-39
33-17-44Ch. 1121 Prior Authorization of Austedo (deutetrabenazine)—
Pharmacy Services12/27/17 01-17-40
02-17-35
03-17-35
08-17-42
09-17-39
11-17-35
14-17-36
24-17-36
27-17-37
30-17-36
31-17-41
32-17-35
33-17-40Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services12/27/17 01-17-38
02-17-33
03-17-33
08-17-40
09-17-37
11-17-33
14-17-34
24-17-34
27-17-35
30-17-34
31-17-39
32-17-33
33-17-38
Ch. 1121 Prior Authorization of Ingrezza (valbenazine)—
Pharmacy Services12/27/17 01-17-39
02-17-34
03-17-34
08-17-41
09-17-38
11-17-34
14-17-35
24-17-35
27-17-36
30-17-35
31-17-40
32-17-34
33-17-39Ch. 1121 Prior Authorization of Brineura (cerliponase alfa)—
Pharmacy Services12/27/17 01-17-41
02-17-36
03-17-36
08-17-43
09-17-40
11-17-36
14-17-37
24-17-37
27-17-38
30-17-37
31-17-42
32-17-36
33-17-41
Ch. 1121 Prior Authorization of Analgesics, Opioid Short Acting—Pharmacy Services 12/14/17 01-17-37
02-17-32
03-17-32
08-17-39
09-17-36
11-17-32
14-17-33
24-17-33
27-17-34
30-17-33
31-17-38
32-17-32
33-17-37Ch. 1163 Hospital Responsibilities Related to the Uncompensated Care Program and Charity Care Plans 12/27/17 01-17-03 Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—Pharmacy Services 12/27/17 01-17-45
02-17-40
03-17-40
08-17-47
09-17-44
11-17-40
14-17-41
24-17-41
27-17-42
30-17-41
31-17-46
32-17-40
33-17-45Ch. 1121 Prior Authorization of Bone Resorption Suppression and Related Agents—Pharmacy Services 12/27/17 01-17-42
02-17-37
03-17-37
08-17-44
09-17-41
11-17-37
14-17-38
24-17-38
27-17-39
30-17-38
31-17-43
32-17-37
33-17-42
Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 12/27/17 01-17-46
02-17-41
03-17-41
08-17-48
09-17-45
11-17-41
14-17-42
24-17-42
27-17-43
30-17-42
31-17-47
32-17-41
33-17-46
2018 Ch. 1101
1150Revised Health Care Benefit Packages Provider Reference Chart (MA 446) 01/02/18 99-18-01 Ch. 1241 Updates to the 2017 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 01/03/18 99-18-02 Ch. 1121 Preferred Drug List (PDL) Update January 8, 2018—
Pharmacy Services01/08/18 01-18-01
02-18-01
03-18-01
08-18-01
09-18-01
11-18-01
14-18-01
24-18-01
27-18-01
30-18-01
31-18-01
32-18-01
33-18-01Ch. 1121 Corrected-Prior Authorization of Hepatitis C Agents—
Pharmacy Services01/22/18 01-18-04
02-18-02
03-18-02
08-18-04
09-18-04
11-18-02
14-18-02
24-18-02
27-18-03
30-18-02
31-18-04
32-18-02
33-18-04Ch. 1101
1150Acupuncturist Enrollment in the Medical Assistance Program 02/21/18 08-18-05
09-18-05
10-18-01
14-18-03
27-18-04
31-18-05
33-18-05
Ch. 1141
1142
1149
1221
1243Clinical Laboratory Improvement Amendments Excluded Laboratory Services Update 02/26/18 01-18-03
08-18-03
09-18-03
27-18-02
28-18-01
31-18-03
33-18-03
Ch. 1221 Addition to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent Flu Vaccine Derived from Cell Cultures, Preservative 03/5/18 01-18-02
08-18-02
09-18-02
31-18-02
33-18-02
Ch. 1101 School-Based ACCESS Program Provider Handbook 03/14/18 35-18-01 Ch. 1221 Prior Authorization of Opioid Dependence Treatments—Pharmacy Services 04/10/18 01-18-06 02-18-04 03-18-04 08-18-07 09-18-07
11-18-04
14-18-05
24-18-04
27-18-06
30-18-04
31-18-07
32-18-04
33-18-07Ch. 1101
1121
1150Update to Submission of Claims that Require the National Provider Identifier (NPI) of a Medical Assistance Enrolled Ordering, Referring or Prescribing Provider 04/16/18 99-18-06 Ch. 1121 Prior Authorization of Analgesics, Opioid Long Acting—Pharmacy Services 04/26/18 01-18-07 09-18-08 27-18-07 33-18-08 02-18-05
11-18-05
30-18-05
03-18-05
14-18-06
31-18-08
08-18-08
24-18-05
32-18-05Ch. 1121 Prior Authorization of Analgesics, Opioid Short Acting—Pharmacy Services 04/26/18 01-18-05
09-18-06
27-18-05
33-18-06
02-18-03
11-18-03
30-18-03
03-18-03
14-18-04
31-18-06
08-18-06
24-18-03
32-18-03Ch. 1241 2018 Recommended Childhood and Adolescent Immunization Schedule 04/27/18 99-18-05 Ch. 1101
1150Update to 180-Day Exception Requests and Invoice Submission Time Frames 05/25/18 99-18-08 Ch. 1101 Reduction of Mailed Paper Remittance Advices 06/15/18 99-18-09 Ch. 1101
1150Enrollment of Tobacco Cessation Providers 06/18/18 99-18-10 Ch. 1101
11502018 Healthcare Common Procedure Coding System (HCPCS) Updates and Other Procedure Code Changes 07/02/18 99-18-07 Ch. 1149 Medical Assistance Program Dental Fee Schedule Update 07/02/18 27-18-08 Ch. 1127
1142
1144
1221
1252Updates to the Family Planning Services Program Fee Schedule 07/02/18 01-18-08 08-18-09 09-18-09 24-18-06 25-18-01 28-18-02 31-18-09 33-18-09 Ch. 1149
1241Updates to the Pediatric Dental Periodicity Schedule 07/03/18 27-18-09 Ch. 1141
1144
1225
1241Childhood Nutrition and Weight Management Services 07/03/18 01-18-09 08-18-10 09-18-10 16-18-01 23-18-01 31-18-10 Ch. 1121 Preferred Drug List (PDL) Update July 23, 2018—
Pharmacy Services07/18/18 01-18-11
02-18-06
03-18-06
08-18-13
09-18-12
11-18-06
14-18-07
24-18-07
27-18-10
30-18-06
31-18-12
32-18-06
33-18-11
Ch. 1121 Prior Authorization of Thalidomide and Derivatives—
Pharmacy Services07/23/18 01-18-23
02-18-18
03-18-18
08-18-25
09-18-24
11-18-18
14-18-19
24-18-19
27-18-22
30-18-18
31-18-24
32-18-18
33-18-23Ch. 1121 Prior Authorization of VMAT2 Inhibitors—Pharmacy Services 07/23/18 01-18-17
02-18-12
03-18-12
08-18-19
09-18-18
11-18-12
14-18-13
24-18-13
27-18-16
30-18-12
31-18-18
32-18-12
33-18-17
Ch. 1121 Prior Authorization of Oncology Agents, Oral—
Pharmacy Services07/23/18 01-18-22
02-18-17
03-18-17
08-18-24
09-18-23
11-18-17
14-18-18
24-18-18
27-18-21
30-18-17
31-18-23
32-18-17
33-18-22
Ch. 1121 Prior Authorization of Immunomodulators, Atopic Dermatitis—Pharmacy Services 07/23/18 01-18-13
02-18-08
03-18-08
08-18-15
09-18-14
11-18-08
14-18-09
24-18-09
27-18-12
30-18-08
31-18-14
32-18-08
33-18-13
Ch. 1121 Prior Authorization of Enzyme Replacements, Gauchers Disease—Pharmacy Services 07/23/18 01-18-20 02-18-15 03-18-15 08-18-22 09-18-21
11-18-15
14-18-16
24-18-16
27-18-19
30-18-15
31-18-21
32-18-15
33-18-20
Ch. 1121 Prior Authorization of Neuropathic Pain Agents—
Pharmacy Services07/23/18 01-18-16
02-18-11
03-18-11
08-18-18
09-18-17
11-18-11
14-18-12
24-18-12
27-18-15
30-18-11
31-18-17
32-18-11
33-18-16Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 07/23/18 01-18-14 02-18-09 03-18-09 08-18-16 09-18-15
11-18-09
14-18-10
24-18-10
27-18-13
30-18-09
31-18-15
32-18-09
33-18-14
Ch. 1121 Prior Authorization of Idiopathic Pulmonary Fibrosis (IPF) Agents—Pharmacy Services 07/23/18 01-18-21 02-18-16 03-18-16 08-18-23 09-18-22
11-18-16
14-18-17
24-18-17
27-18-20
30-18-16
31-18-22
32-18-16
33-18-21
Ch. 1121 Prior Authorization of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)—Pharmacy Services 07/23/18 01-18-18 02-18-13 03-18-13 08-18-20 09-18-19
11-18-13
14-18-14
24-18-14
27-18-17
30-18-13
31-18-19
32-18-13
33-18-18
Ch. 1121 Prior Authorization of Monoclonal Antibodies—Anti-IL, Anti-IgE (MABs-Anti-IL, Anti-IgE)—Pharmacy Services 07/23/18 01-18-15
02-18-10
03-18-10
08-18-17
09-18-16
11-18-10
14-18-11
24-18-11
27-18-14
30-18-13
31-18-19
32-18-13
33-18-18
Ch. 1121 Prior Authorization of Analgesics, Non-Opioid Barbiturate Combinations—Pharmacy Services 07/23/18 01-18-12
02-18-07
03-18-07
08-18-14
09-18-13
11-18-07
14-18-08
24-18-08
27-18-11
30-18-07
31-18-13
32-18-07
33-18-12Ch. 1121 Prior Authorization of Bone Resorption Suppression and Related Agents—Pharmacy Services 07/23/18 01-18-19
02-18-14
03-18-14
08-18-21
09-18-13
11-18-07
14-18-08
24-18-08
27-18-11
30-18-07
31-18-13
32-18-07
33-18-12
Ch. 1241 Updates to Pennsylvania's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 08/01/18 99-18-13 Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—Pharmacy Services 08/13/18 01-18-24 Ch. 1241 Environmental Lead Investigations 08/22/18 01-18-10
08-18-11
09-18-11
31-18-11
33-18-10
55-18-01
Ch. 1101 School-Based ACCESS Program Provider Handbook 09/19/18 35-18-02 Ch. 1121 Professional Dispensing Fee—Pharmacy Services 10/04/18 35-18-02 Ch. 1187
1189Changes to Managed Care Coverage of Nursing Facility Services 11/21/18 03-18-20 Ch. 1121 Prior Authorization of Antimigraine Agents—Pharmacy Services 12/12/18 01-18-27
02-18-22
03-18-23
08-18-30
09-18-28
11-18-22
14-18-23
24-18-24
27-18-27
30-18-22
31-18-28
32-18-22
33-18-27Ch. 1121 Prior Authorization of Angiotensin Modulators—Pharmacy Services 12/12/18 01-18-26
02-18-21
03-18-22
08-18-29
09-18-27
11-18-21
14-18-22
24-18-23
27-18-26
30-18-21
31-18-27
32-18-21
33-18-26Ch. 1121 Prior Authorization of Angiotensin Modulator Combinations—Pharmacy Services 12/12/18 01-18-25
02-18-20
03-18-24
08-18-28
09-18-26
11-18-20
14-18-21
24-18-22
27-18-25
30-18-20
31-18-26
32-18-20
33-18-25
Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/12/18 01-18-28
02-18-23
03-18-24
08-18-31
09-18-29
11-18-23
14-18-24
24-18-25
27-18-28
30-18-23
31-18-29
32-18-23
33-18-28Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—Pharmacy Services 12/12/18 01-18-36
02-18-31
03-18-32
08-18-39
09-18-37
11-18-31
14-18-32
24-18-33
27-18-36
30-18-31
31-18-37
32-18-31
33-18-36
Ch. 1121 Prior Authorization of Hypoglycemics, Insulin and Related Agents—Pharmacy Services 12/13/18 01-18-30
02-18-25
03-18-26
08-18-33
09-18-31
11-18-25
14-18-26
24-18-27
27-18-30
30-18-25
31-18-31
32-18-25
33-18-30Ch. 1121 Prior Authorization of Hypoglycemics, TZDs—
Pharmacy Services12/13/18 01-18-33
02-18-28
03-18-29
08-18-36
09-18-34
11-18-28
14-18-29
24-18-30
27-18-33
30-18-28
31-18-34
32-18-28
33-18-33Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 12/13/18 01-18-31
02-18-26
03-18-27
08-18-34
09-18-32
11-18-26
14-18-27
24-18-28
27-18-31
30-18-26
31-18-32
32-18-26
33-18-31Ch. 1121 Prior Authorization of Hypoglycemics, Incretin Mimetics/Enhancers—Pharmacy Services 12/13/2018 01-18-29
02-18-24
03-18-25
08-18-32
09-18-30
11-18-24
14-18-25
24-18-26
27-18-29
30-18-24
31-18-30
32-18-24
33-18-29Ch. 1121 Prior Authorization of Oncology Agents, Oral—
Pharmacy Services12/13/18 01-18-34
02-18-29
03-18-30
08-18-37
09-18-35
11-18-29
14-18-30
24-18-31
27-18-34
30-18-29
31-18-35
32-18-29
33-18-34
Ch. 1121 Prior Authorization of Kalydeco (ivacaftor)—Pharmacy Services 12/13/18 01-18-32 02-18-27 03-18-28 08-18-35 09-18-33
11-18-27
14-18-28 24-18-29 27-18-32 30-18-27 31-18-33 32-18-27 33-18-32Ch. 1121 Prior Authorization of Orkambi (lumacaftor/ivacaftor)—Pharmacy Services 12/13/18 01-18-35
02-18-30
03-18-31
08-18-38
09-18-36
11-18-30
14-18-31
24-18-32
27-18-35
30-18-30
31-18-36
32-18-30
33-18-35
Ch. 1101 Service Location Enrollment Deadline 12/19/18 99-18-11 Ch. 1245 Fee Increases for Certain Ambulance Transportation Services 12/24/18 26-18-01 Ch. 1243 Updates to Laboratory Services on the Medical Assistance Program Fee Schedule; Prior Authorization for Noninvasive Prenatal Screening (NiPS) 01/02/19 01-19-01
08-19-01
09-19-01
28-19-01
31-19-01
33-19-01Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 01/18/19 01-19-06
02-19-05
03-19-05
08-19-08
09-19-06
11-19-05
14-19-05
24-19-05
27-19-06
30-19-05
31-19-06
32-19-05
33-19-06Ch. 1121 Preferred Drug List (PDL) Update January 28, 2019—
Pharmacy Services01/18/19 01-19-04
02-19-03
03-19-03
08-19-06
09-19-04
11-19-03
14-19-03
24-19-03
27-19-04
30-19-03
31-19-04
32-19-03
33-19-04
Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services01/18/19 01-19-10
02-19-09
03-19-09
08-19-12
09-19-10
11-19-09
14-19-09
24-19-09
27-19-10
30-19-09
31-19-10
32-19-09
33-19-10Ch. 1121 Prior Authorization of Antiparkinson's Agents—
Pharmacy Services01/18/19 01-19-09
02-19-08
03-19-08
08-19-11
09-19-09
11-19-08
14-19-08
24-19-08
27-19-09
30-19-08
31-19-09
32-19-08
33-19-09
Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled—
Pharmacy Services01/18/19 01-19-07
02-19-06
03-19-06
08-19-09
09-19-07
11-19-06
14-19-06
24-19-06
27-19-07
30-19-06
31-19-07
32-19-06
33-19-07Ch. 1121 Prior Authorization of Alpha-1 Proteinase Inhibitors—Pharmacy Services 01/18/19 01-19-08
02-19-07
03-19-07
08-19-10
09-19-08
11-19-07
14-19-07
24-19-07
27-19-08
30-19-07
31-19-08
32-19-07
33-19-08
Ch. 1121 Prior Authorization of Antihyperuricemics—Pharmacy Services 01/18/19 01-19-05
02-19-04
03-19-04
08-19-07
09-19-05
11-19-04
14-19-04
24-19-04
27-19-05
30-19-04
31-19-05
32-19-04
33-19-05
Ch. 1121 Prior Authorization of Radicava (edaravone)—
Pharmacy Services01/21/19 01-19-03
02-19-02
03-19-02
08-19-04
09-19-03
11-19-02
14-19-02
24-19-02
27-19-02
30-19-02
31-19-03
32-19-02
33-19-03Ch. 1121 Prior Authorization of Symdeko (tezacaftor/ivacaftor)—
Pharmacy Services01/21/19 01-19-02
02-19-01
03-19-01
08-19-03
09-19-02
11-19-01
14-19-01
24-19-01
27-19-01
30-19-01
31-19-02
32-19-01
33-19-02
Ch.1101 1150 Changes to Third-Party Liability Requirements for Claims for Prenatal Services 03/01/19 01-19-12
05-19-01
08-19-14
09-19-12
31-19-12
33-19-12
47-19-01
Ch. 1101 1150 Update to the Administration of the Human Papillomavirus (HPV) Vaccine 04/05/19 01-19-11
08-19-13
09-19-11
31-19-11
33-19-11Ch. 1241 2019 Recommended Childhood and Adolescent Immunization Schedule 04/22/19 99-19-01 GUIDANCE MANUALS:
• Provider Handbook—Physician—updated 10/2017
• Provider Handbook—Dentist—updated 10/2017
• Provider Handbook—Podiatrist—updated 10/2017
• Provider Handbook—Medical Supplier—updated 10/2017
• Provider Handbook—Short Procedure Unit/Ambulatory Surgical Center—updated 10/2017
• Provider Handbook—Chiropractor—updated 10/2017
• Provider Handbook—Birth Centers—updated 10/2017
• Provider Handbook—Independent Medical/Surgical Clinic—updated 10/2017
• Provider Handbook—Inpatient Hospital (Encompasses provider types General Hospital, Rehabilitation Hospital, Private Mental Hospital, State Mental Hospital and Extended Acute Psychiatric Care—updated 10/2017
• Provider Handbook—Outpatient Hospital (Encompasses provider types General Hospital, and Rehabilitation Hospital)—
updated 10/2017
• Provider Handbook—Optometrist—updated 10/2017
• Provider Handbook—Independent Laboratory—updated 10/2017
• Provider Handbook—Ambulance Company—updated 10/2017
• Provider Handbook—Pharmacy—updated 10/2017
• Provider Handbook—Portable X-Ray Provider—updated 10/2017
• Provider Handbook—Renal Dialysis Center—updated 10/2017
• Provider Handbook—Funeral Director—updated 10/2017
• Provider Handbook—Home Health Agency—updated 10/2017
• Provider Handbook—Rural Health Clinic—updated 10/2017
• Provider Handbook—Drug and Alcohol Clinic—updated 10/2017
• Provider Handbook—Outpatient Psychiatric Clinic—updated 10/2017
• Provider Handbook—Family Planning Clinic—updated 10/2017
• Provider Handbook—Midwives—updated 10/2017
• Provider Handbook—Psychiatric Partial Hospitalization Facility—updated 10/2017
• Provider Handbook—Hospice—updated 10/2017
• Provider Handbook—Psychologist—updated 10/2017
• Provider Handbook—Comprehensive Outpatient Rehabilitation Facility—updated 10/2017
• Provider Handbook—Physical Therapist—updated 10/2017
• Provider Handbook—Certified RN Anesthetist—updated 10/2017
• Provider Handbook—Certified RN Practitioner—updated 10/2017
• Provider Handbook—Early Periodic Screening, Diagnosis and Treatment (EPSDT) Provider updated 10/2017
• Provider Handbook—Nutritionist—updated 10/2017
• Provider Handbook—PA Department of Aging (PDA) Waiver—updated 10/2017
• Provider Handbook—COMMCARE Waiver updated 10/2017
• Medical Assistance Transportation Program—Standards and Guidelines updated 11/2016OTHER:
• PA 67 Section 1915(b) Waiver
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