[51 Pa.B. 4433]
[Saturday, August 7, 2021]
[Continued from previous Web Page] (Editor's Note: This document continues from Part III which begins at 51 Pa.B. 4565 (August 7, 2021).)
Year Code Citation Subject Date Issued Bulletin Number Ch. 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 Vaccine 02/18/15 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 Services 05/11/15 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 Services06/25/15 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 Services 06/25/15 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 Services06/25/15 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 06/29/15 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 Service07/13/15 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 1150 Prior Authorization Requirements and Fee Schedule Updates for Hyperbaric Oxygen Therapy 08/31/15 01-15-30
14-15-25
31-15-30
Ch. 1101 1150 2015 HCPCS Updates and Other Procedure Codes 08/31/15 99-15-06 Ch. 1101 1150 Procedure 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 1150 Medical 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 1150 New 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 Service11/10/15 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 33-15-34Ch. 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 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 33-15-31Ch. 1163 Revised Procedures for Presumptive Eligibility as Determined by Hospitals 11/30/15 01-15-32 Ch. 1121 Prior Authorization of Corlanor (ivabradine)—Pharmacy 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 33-15-36Ch. 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 33-15-26 Ch. 1121 Prior Authorization of Orkambi (lumacaftor/ivacaftor)—
Pharmacy Service11/30/15 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 1150 The 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 1249 Hospice 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 33-16-01Ch. 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 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 33-16-04Ch. 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 33-16-03Ch. 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 Service01/06/16 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 33-16-05Ch. 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 32-16-09Ch. 1121 Prior Authorization of Stimulants and Related Agents—
Pharmacy Service03/14/16 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 33-16-10Ch. 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 33-16-13Ch. 1121 Prior Authorization of Xofigo (radium Ra 223 dichloride)—
Pharmacy Service06/13/16 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 33-16-16Ch. 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 33-16-19Ch. 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 33-16-17Ch. 1121 Prior Authorization of Cephalosporins and Related Agents—
Pharmacy Services07/05/16 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 33-16-25Ch. 1121 Preferred Drug List (PDL) Update July 18, 2016—
Pharmacy Services07/05/16 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 33-16-23Ch. 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 33-16-18Ch. 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 33-16-22Ch. 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 33-16-24Ch. 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 33-16-21Ch. 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 1249 Medical 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 33-16-27Ch. 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 33-16-28Ch. 1101 Services Ordered, Referred, or Prescribed By Graduate Medical or Osteopathic Trainees 11/02/16 01-16-32 31-16-34 Ch. 1101 1225 MA 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 Service01/04/17 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 1150 Submission 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 33-17-05Ch. 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 33-17-08Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—
Pharmacy Services01/30/17 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 Services01/30/17 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 33-17-03Ch. 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 33-17-06Ch. 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 33-17-14Ch. 1121 Prior Authorization of Stimulants and Related Agents—
Pharmacy Services01/31/17 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 33-17-15Ch. 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 33-17-16Ch. 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 Services04/27/17 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 33-17-21Ch. 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 33-17-22Ch. 1121 Prior Authorization of Exondys 51 (eteplirsen)—Pharmacy Services 06/07/17 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 33-17-23Ch. 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 33-17-24Ch. 1121 Prior Authorization of Oncology Agents, Breast Cancer—
Pharmacy Services06/07/17 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 Services 06/07/17 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 33-17-29Ch. 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 33-17-33Ch. 1121 Preferred Drug List (PDL) Update July 25, 2017—
Pharmacy Services07/21/17 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 33-17-31Ch. 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 1150 2017 Healthcare Common Procedure Coding System (HCPCS) Updates and Other Procedure Code Changes 08/07/17 99-17-08 Ch. 1101 1150 Pasteurized 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 1150 Procedure 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 33-17-32Ch. 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 Services12/14/17 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 33-17-35Ch. 1121 Prior Authorization of Analgesics, Opioid Long Acting—
Pharmacy Services12/27/17 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 33-17-38Ch. 1121 Prior Authorization of Ingrezza (valbenazine)—Pharmacy Services 12/27/17 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 33-17-41Ch. 1121 Prior Authorization of Analgesics, Opioid Short Acting—
Pharmacy Services12/14/17 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 Services12/27/17 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 33-17-42Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services12/27/17 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 33-17-462018 Ch. 1101 1150 Revised 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 1150 Acupuncturist 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 Services04/10/18 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 Services04/26/18 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 Services04/26/18 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 1150 Update 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 1150 Enrollment of Tobacco Cessation Providers 06/18/18 99-18-10 Ch. 1101 1150 2018 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 1241 Updates 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
33-18-11Ch. 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 33-18-17Ch. 1121 Prior Authorization of Oncology Agents, Oral—Pharmacy Services 07/23/18 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 33-18-22Ch. 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 33-18-13Ch. 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 33-18-20Ch. 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 33-18-14Ch. 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 33-18-21Ch. 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 33-18-18Ch. 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 33-18-18Ch. 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 33-18-12Ch. 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 Services08/13/18 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 55-18-01Ch. 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 1189 Changes 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 33-18-25Ch. 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 Services12/12/18 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 33-18-36Ch. 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 Services 12/13/18 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 Services12/13/18 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 Services12/13/2018 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 Services 12/13/18 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 33-18-34Ch. 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 Services12/13/18 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 33-18-35Ch. 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 2019 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 33-19-01 Ch. 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 33-19-04Ch. 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 Services 01/18/19 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 33-19-09Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled—Pharmacy Services 01/18/19 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 Services01/18/19 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 33-19-08Ch. 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 33-19-05Ch. 1121 Prior Authorization of Radicava (edaravone)—Pharmacy Services 01/21/19 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 33-19-02Ch.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 Ch. 1121 Prior Authorization of Dupixent (dupilumab)—Pharmacy Services 6/27/19 01-19-16
02-19-11
03-19-11
08-19-17 09-19-15
11-19-11
14-19-11
24-19-13 27-19-12
30-19-11
31-19-16
32-19-11
33-19-15Ch. 1121 Prior Authorization of Immunomodulators, Atopic Dermatitis—Pharmacy Services 6/27/19 01-19-17 02-19-12 03-19-12 08-19-18 09-19-16
11-19-12
14-19-12 24-19-14 27-19-13 30-19-12 31-19-17 32-19-12 33-19-16Ch. 1121 Prior Authorization of Antibiotics, Inhaled—Pharmacy Services 6/27/19 01-19-15 02-19-10 03-19-10 08-19-16 09-19-14
11-19-10
14-19-10 24-19-12
27-19-11
30-19-10 31-19-15 32-19-10 33-19-14Ch. 1121 Prior Authorization of Complement Inhibitors—Pharmacy Services 6/27/19 01-19-19 02-19-14 03-19-14 08-19-20 09-19-18
11-19-14
14-19-14 24-19-16 27-19-15 30-19-14 31-19-19 32-19-14 33-19-18Ch. 1121 Prior Authorization of Calcium Channel Blockers—
Pharmacy Services6/27/19 01-19-20 02-19-15 03-19-15 08-19-21 09-19-19
11-19-15
14-19-15 24-19-17 27-19-16 30-19-15 31-19-20 32-19-15 33-19-19Ch. 1121 Prior Authorization of Xyrem (sodium oxybate)—Pharmacy Services 6/27/19 01-19-18 02-19-13 03-19-13 08-19-19 09-19-17
11-19-13
14-19-13 24-19-15 27-19-14 30-19-13 31-19-18 32-19-13 33-19-17Ch. Certified Recovery Specialists in Centers of Excellence 7/17/19 01-19-46 08-19-48
11-19-39
19-19-01 21-19-01 31-19-45Ch. 1121 Prior Authorization of Antimigraine Agents, Other—
Pharmacy Services7/30/19 01-19-37 02-19-32 03-19-31 08-19-40 09-19-35
11-19-31
14-19-31 24-19-33 27-19-33 30-19-31 31-19-37 32-19-31 33-19-35Ch. 1121 Prior Authorization of Acne Agents, Oral—Pharmacy Services 7/30/19 01-19-34 02-19-29 03-19-28 08-19-37 09-19-32
11-19-28
14-19-28 24-19-30 27-19-30 30-19-28 31-19-34 32-19-28 33-19-32Ch. 1121 Prior Authorization of Antimalarials—Pharmacy Services 7/31/19 01-19-38 02-19-33 03-19-32 08-19-41 09-19-36
11-19-32
14-19-32 24-19-34 27-19-34 30-19-32 31-19-38 32-19-32 33-19-36Ch. 1121 Prior Authorization of Antianginal Agents—Pharmacy Services 7/31/19 01-19-39 02-19-34 03-19-33 08-19-42 09-19-37
11-19-33
14-19-33 24-19-35 27-19-35 30-19-33 31-19-39 32-19-33 33-19-37Ch. 1121 Prior Authorization of Angiotensin Modulators—Pharmacy Services 7/31/19 01-19-40 02-19-35 03-19-34 08-19-43 09-19-38
11-19-34
14-19-34 24-19-36 27-19-36 30-19-34 31-19-40 32-19-34 33-19-38Ch. 1121 Prior Authorization of Local Anesthetics, Topical—
Pharmacy Services8/8/19 01-19-25 02-19-20 03-19-19 08-19-28 09-19-23
11-19-19
14-19-19 24-19-21 27-19-21 30-19-19 31-19-25 32-19-19 33-19-23Ch. 1121 Prior Authorization of Thalidomide and Derivatives—
Pharmacy Services8/8/19 01-19-22 02-19-17 03-19-16 08-19-25 09-19-20
11-19-16
14-19-16 24-19-18 27-19-18 30-19-16 31-19-22 32-19-16 33-19-20Ch. 1121 Prior Authorization of HIV/AIDS Antiretrovirals—
Pharmacy Services8/8/19 01-19-26 02-19-21 03-19-20 08-19-29 09-19-24
11-19-20
14-19-20 24-19-22 27-19-22 30-19-20 31-19-26 32-19-20 33-19-24Ch. 1121 Prior Authorization of Colony Stimulating Factors—
Pharmacy Services8/8/19 01-19-27 02-19-22 03-19-21 08-19-30 09-19-25
11-19-21
14-19-21 24-19-23 27-19-23 30-19-21 31-19-27 32-19-21 33-19-25Ch. 1121 Prior Authorization of Monoclonal Antibodies—Anti-IL, Anti-IgE (MABs—Anti-IL, Anti-IgE)—Pharmacy Services 8/8/19 01-19-24 02-19-19 03-19-18 08-19-27 09-19-22
11-19-18
14-19-18 24-19-20 27-19-20 30-19-18 31-19-24 32-19-18 33-19-22Ch. 1121 Prior Authorization of Cephalosporins—Pharmacy Services 8/8/19 01-19-28 02-19-23 03-19-22 08-19-31 09-19-26
11-19-22
14-19-22 24-19-24 27-19-24 30-19-22 31-19-28 32-19-22 33-19-26Ch. 1121 Prior Authorization of Penicillins—Pharmacy Services 8/8/19 01-19-23 02-19-18 03-19-17 08-19-26 09-19-21
11-19-17
14-19-17 24-19-19 27-19-19 30-19-17 31-19-23 32-19-17 33-19-21Ch. 1101 1150 2019 Healthcare Common Procedure Code System (HCPCS) Updates, Fee Adjustments and Other Procedure Code Changes 8/19/19 99-19-04 Ch. 1241 Pennsylvania's Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 8/19/19 99-19-02 Ch. 1121 Prior Authorization of Bone Density Regulators—
Pharmacy Services8/20/19 01-19-32 02-19-27 03-19-26 08-19-35 09-19-30
11-19-26
14-19-26 24-19-28 27-19-28 30-19-26 31-19-32 32-19-26 33-19-30Ch. 1121 Prior Authorization of H. Pylori Treatments—Pharmacy Services 8/20/19 01-19-44 02-19-39 03-19-38 08-19-47 09-19-42
11-19-38
14-19-38 24-19-40 27-19-40 30-19-38 31-19-44 32-19-38 33-19-42Ch. 1121 Prior Authorization of Antivirals, Herpes—Pharmacy Services 8/20/19 01-19-35 02-19-30 03-19-29 08-19-38 09-19-33
11-19-29
14-19-29 24-19-31 27-19-31 30-19-29 31-19-35 32-19-29 33-19-33Ch. 1121 Prior Authorization of Antivirals, Influenza—Pharmacy Services 8/20/19 01-19-33 02-19-28 03-19-27 08-19-36 09-19-31
11-19-27
14-19-27 24-19-29 27-19-29 30-19-27 31-19-33 32-19-27 33-19-31Ch. 1121 Prior Authorization of Antivirals, CMV—Pharmacy Services 8/20/19 01-19-36 02-19-31 03-19-30 08-19-39 09-19-34
11-19-30
14-19-30 24-19-32 27-19-32 30-19-30 31-19-36 32-19-30 33-19-34Ch. 1121 Prior Authorization of Vaginal Anti-Infectives—Pharmacy Services 8/21/19 01-19-30 02-19-25 03-19-24 08-19-33 09-19-28
11-19-24
14-19-24 24-19-26 27-19-26 30-19-24 31-19-30 32-19-24 33-19-28Ch. 1121 Prior Authorization of Thrombopoietics—Pharmacy Services 8/21/19 01-19-41 02-19-36 03-19-35 08-19-44 09-19-39
11-19-35
14-19-35 24-19-37 27-19-37 30-19-35 31-19-41 32-19-35 33-19-39Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 8/21/19 01-19-43 02-19-38 03-19-37 08-19-46 09-19-41
11-19-37
14-19-37 24-19-39 27-19-39 30-19-37 31-19-43 32-19-37 33-19-41Ch. 1121 Prior Authorization of COPD Agents—Pharmacy Services 8/21/19 01-19-42 02-19-37 03-19-36 08-19-45 09-19-40
11-19-36
14-19-36 24-19-38 27-19-38 30-19-36 31-19-19 32-19-36 33-19-40Ch. 1121 Prior Authorization of Vitamin D Analogs—Pharmacy Services 8/21/19 01-19-29 02-19-24 03-19-23 08-19-32 09-19-27
11-19-23
14-19-23 24-19-25 27-19-25 30-19-23 31-19-29 32-19-23 33-19-27Ch. 1121 Prior Authorization of Urinary Anti-Infectives—Pharmacy Services 8/21/19 01-19-31 02-19-26 03-19-25 08-19-34 09-19-29
11-19-25
14-19-25 24-19-27 27-19-27 30-19-25 31-19-31 32-19-25 33-19-29Ch. 1101 Corrected—Diabetes Prevention Program Enrollment in the Medical Assistance Program 8/22/19 99-19-06 Ch. 1225 Family Planning Services Program 8/23/19 01-19-13 08-19-15 09-19-13 24-19-10 25-19-01 28-19-02 31-19-13 33-19-13 Ch. 1121 Prior Authorization of Antihyperuricemics—Pharmacy Services 9/3/19 01-19-50 02-19-44 03-19-43 08-19-52 09-19-46
11-19-43
14-19-42 24-19-44 27-19-44 30-19-42 31-19-49 32-19-42 33-19-46Ch. 1121 Prior Authorization of Intranasal Rhinitis Agents—
Pharmacy Services9/3/19 01-19-62 02-19-56 03-19-55 08-19-64 09-19-58
11-19-55
14-19-54 24-19-56 27-19-56 30-19-54 31-19-61 32-19-54 33-19-58Ch. 1121 Prior Authorization of Antihistamines, Minimally Sedating—
Pharmacy Services9/3/19 01-19-51 02-19-45 03-19-44 08-19-53 09-19-47
11-19-44
14-19-43 24-19-45 27-19-45 30-19-43 31-19-50 32-19-43 33-19-47Ch. 1121 Prior Authorization of Antihemophilia Agents—Pharmacy Services 9/3/19 01-19-52 02-19-46 03-19-45 08-19-54 09-19-48
11-19-45
14-19-44 24-19-46 27-19-46 30-19-44 31-19-51 32-19-44 33-19-48Ch. 1121 Prior Authorization of Estrogens—Pharmacy Services 9/4/19 01-19-54 02-19-48 03-19-47 08-19-56 09-19-50
11-19-47
14-19-46 24-19-48 27-19-48 30-19-46 31-19-53 32-19-46 33-19-50Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 9/4/19 01-19-53 02-19-47 03-19-46 08-19-55 09-19-49
11-19-46
14-19-45 24-19-47 27-19-47 30-19-45 31-19-52 32-19-45 33-19-49Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—
Pharmacy Services9/4/19 01-19-58 02-19-52 03-19-51 08-19-60 09-19-54
11-19-51
14-19-50 24-19-52 27-19-52 30-19-50 31-19-57 32-19-50 33-19-54Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—
Pharmacy Services9/4/19 01-19-49 02-19-43 03-19-42 08-19-51 09-19-45
11-19-42
14-19-41 24-19-43 27-19-43 30-19-41 31-19-48 32-19-41 33-19-45Ch. 1121 Prior Authorization of Iron Chelating Agents—Pharmacy Services 9/5/19 01-19-61 02-19-55 03-19-54 08-19-63 09-19-57
11-19-54
14-19-53 24-19-55 27-19-55 30-19-53 31-19-60 32-19-53 33-19-57Ch. 1121 Prior Authorization of Oncology Agents, Breast Cancer—
Pharmacy Services9/5/19 01-19-59 02-19-53 03-19-52 08-19-61 09-19-55
11-19-52
14-19-51 24-19-53 27-19-53 30-19-51 31-19-58 32-19-51 33-19-55Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services9/5/19 01-19-60 02-19-54 03-19-53 08-19-62 09-19-56
11-19-53
14-19-52 24-19-54 27-19-54 30-19-52 31-19-59 32-19-52 33-19-56Ch. 1121 Prior Authorization of Ophthalmics, Anti-Inflammatories—
Pharmacy Services9/10/19 01-19-56 02-19-50 03-19-49 08-19-58 09-19-52
11-19-49
14-19-48 24-19-50 27-19-50 30-19-48 31-19-55 32-19-48 33-19-52Ch. 1121 Prior Authorization of Urea Cycle Disorder Agents—
Pharmacy Services9/10/19 01-19-57 02-19-51 03-19-50 08-19-59 09-19-53
11-19-50
14-19-49 24-19-51 27-19-51 30-19-49 31-19-56 32-19-49 33-19-53Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 9/10/19 01-19-55 02-19-49 03-19-48 08-19-57 09-19-51
11-19-48
14-19-47 24-19-49 27-19-49 30-19-47 31-19-54 32-19-47 33-19-51Ch. 1121 Prior Authorization of Ulcerative Colitis Agents—
Pharmacy Services9/10/19 01-19-48 02-19-42 03-19-41 08-19-50 09-19-44
11-19-41
14-19-40 24-19-42 27-19-42 30-19-40 31-19-47 32-19-40 33-19-44Ch. 1121 Prior Authorization of Stimulants and Related Agents—
Pharmacy Services9/11/19 01-19-64 02-19-58 03-19-57 08-19-66 09-19-60
11-19-57
14-19-56 24-19-58 27-19-58 30-19-56 31-19-63 32-19-56 33-19-60Ch. 1121 Prior Authorization of Potassium Removing Agents—
Pharmacy Services9/11/19 01-19-47 02-19-41 03-19-40 08-19-49 09-19-43
11-19-40
14-19-39 24-19-41 27-19-41 30-19-39 31-19-46 32-19-39 33-19-43Ch. 1121 Prior Authorization of Hypoglycemics, Meglitinides—
Pharmacy Services9/16/19 01-19-63 02-19-57 03-19-56 08-19-65 09-19-59
11-19-56
14-19-55 24-19-57 27-19-57 30-19-55 31-19-62 32-19-55 33-19-59Ch. 1101 School-Based ACCESS Program Provider Handbook 9/19/19 35-19-01 Ch. 1225 Updates to Sterilization Consent Form (MA 31) 9/27/19 01-19-21 02-19-16 08-19-22 31-19-21 Ch. 1121 Statewide Preferred Drug List (PDL) Implementation—
Pharmacy Services10/10/19 01-19-65 02-19-59 03-19-58 08-19-67 09-19-61
11-19-58
14-19-57 24-19-59 27-19-59 30-19-57 31-19-64 32-19-57 33-19-61Ch. 1121 Prior Authorization of Antimigraine Agents, Triptans—
Pharmacy Services10/16/19 01-19-94 02-19-88 03-19-87 08-19-96 09-19-90
11-19-87
14-19-86 24-19-88 27-19-88 30-19-86 31-19-93 32-19-86 33-19-90Ch. 1121 Prior Authorization of Fluoroquinolones, Oral—Pharmacy Services 10/16/19 01-19-83 02-19-77 03-19-76
08-19-85 09-19-79
11-19-76
14-19-75 24-19-77 27-19-77 30-19-75 31-19-82 32-19-75 33-19-79Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 10/16/19 01-19-86 02-19-80 03-19-79 08-19-88 09-19-82
11-19-79
14-19-78 24-19-80 27-19-80 30-19-78 31-19-85 32-19-78 33-19-82Ch. 1121 Prior Authorization of Glucocorticoids, Inhaled—Pharmacy Services 10/16/19 01-19-79 02-19-73 03-19-72 08-19-81 09-19-75
11-19-72
14-19-71 24-19-73 27-19-73 30-19-71 31-19-78 32-19-71 33-19-75Ch. 1121 Prior Authorization of Blood Glucose Meters and Test Strips (Formerly Diabetic Meters and Diabetic Strips)—Pharmacy Services 10/16/19 01-19-84 02-19-78 03-19-77 08-19-86 09-19-80
11-19-77
14-19-76 24-19-78 27-19-78 30-19-76 31-19-83 32-19-76 33-19-80Ch. 1121 Prior Authorization of BPH Treatments—Pharmacy Services 10/17/19 01-19-97 02-19-91 03-19-90 08-19-99 09-19-93
11-19-90
14-19-89 24-19-91 27-19-91 30-19-89 31-19-96 32-19-89 33-19-93Ch. 1121 Prior Authorization of Antifungals, Oral—Pharmacy Services 10/17/19 01-19-82 02-19-76 03-19-75 08-19-84 09-19-78
11-19-75
14-19-74 24-19-76 27-19-76 30-19-74 31-19-81 32-19-74 33-19-78Ch. 1121 Prior Authorization of Antidepressants, SSRIs—Pharmacy Services 10/17/19 01-19-85 02-19-79 03-19-78 08-19-87 09-19-81
11-19-78
14-19-77 24-19-79 27-19-79 30-19-77 31-19-84 32-19-77 33-19-81Ch. 1121 Prior Authorization of Antiemetic/Antivertigo Agents—
Pharmacy Services10/17/19 01-19-88 02-19-82 03-19-81 08-19-90 09-19-84
11-19-81
14-19-80 24-19-82 27-19-82 30-19-80 31-19-87 32-19-80 33-19-84Ch. 1121 Prior Authorization of Acne Agents, Topical—Pharmacy Services 10/17/19 01-19-87 02-19-81 03-19-80 08-19-89 09-19-83
11-19-80
14-19-79 24-19-81 27-19-81 30-19-79 31-19-86 32-19-79 33-19-83Ch. 1121 Prior Authorization of Histamine 2 (H2) Receptor Blockers—
Pharmacy Services10/18/19 01-19-96 02-19-90 03-19-89 08-19-98 09-19-92
11-19-89
14-19-88 24-19-90 27-19-90 30-19-88 31-19-95 32-19-88 33-19-92Ch. 1121 Prior Authorization of Growth Factors—Pharmacy Services 10/18/19 01-19-78 02-19-72 03-19-71 08-19-80 09-19-74
11-19-71
14-19-70 24-19-72 27-19-72 30-19-70 31-19-77 32-19-70 33-19-74Ch. 1121 Prior Authorization of Intra-Articular Hyaluronates—
Pharmacy Services10/21/19 01-19-81 02-19-75 03-19-74 08-19-83 09-19-77
11-19-74
14-19-73 24-19-75 27-19-75 30-19-73 31-19-80 32-19-73 33-19-77Ch. 1121 Prior Authorization of Immunosuppressives, Oral—
Pharmacy Services10/21/19 01-19-76 02-19-70 03-19-69 08-19-78 09-19-72
11-19-69
14-19-68 24-19-70 27-19-70 30-19-68 31-19-75 32-19-68 33-19-72Ch. 1121 Prior Authorization of Idiopathic Pulmonary Fibrosis (IPF) Agents—Pharmacy Services 10/21/19 01-19-77 02-19-71 03-19-70 08-19-79 09-19-73
11-19-70
14-19-69 24-19-71 27-19-71 30-19-69 31-19-76 32-19-69 33-19-73Ch. 1121 Prior Authorization of Ophthalmics, Allergic Conjunctivitis (Formerly Ophthalmic Agents for Allergic Conjunctivitis)—
Pharmacy Services10/25/19 01-19-72 02-19-66 03-19-65 08-19-74 09-19-68
11-19-64
14-19-64 24-19-66 27-19-66 30-19-64 31-19-71 32-19-64 33-19-68Ch. 1121 Prior Authorization of Ophthalmics, Immunomodulators (Formerly Ophthalmic Immunomodulators)—Pharmacy Services 10/25/19 01-19-68 02-19-62 03-19-61 08-19-70 09-19-64
11-19-61
14-19-60 24-19-62 27-19-62 30-19-60 31-19-67 32-19-60 33-19-64Ch. 1121 Prior Authorization of Macrolides (Formerly Macrolides/Ketolides)—Pharmacy Services 10/25/19 01-19-74 02-19-68 03-19-67 08-19-76 09-19-70
11-19-67
14-19-66 24-19-68 27-19-68 30-19-66 31-19-73 32-19-66 33-19-70Ch. 1121 Prior Authorization of Opioid Overdose Agents (Formerly Opiate Overdose Agents)—Pharmacy Services 10/25/19 01-19-67 02-19-61 03-19-60 08-19-69 09-19-63
11-19-60
14-19-59 24-19-61 27-19-61 30-19-59 31-19-66 32-19-59 33-19-63Ch. 1121 Prior Authorization of Ophthalmics, Glaucoma
(Formerly Ophthalmic Agents for Glaucoma)—Pharmacy Services10/25/19 01-19-75 02-19-69 03-19-68 08-19-77 09-19-71
11-19-68
14-19-67 24-19-69 27-19-69 30-19-67 31-19-74 32-19-67 33-19-71Ch. 1121 Prior Authorization of Iron, Oral—Pharmacy Services 10/28/19 01-19-95 02-19-89 03-19-88 08-19-97 09-19-91
11-19-88
14-19-87 24-19-89 27-19-89 30-19-87 31-19-94 32-19-87 33-19-91Ch. 1121 Prior Authorization of Neuropathic Pain Agents—
Pharmacy Services10/28/19 01-19-73 02-19-67 03-19-66 08-19-75 09-19-69
11-19-66
14-19-65 24-19-67 27-19-67 30-19-65 31-19-72 32-19-65 33-19-69Ch. 1121 Prior Authorization of Iron, Parenteral—Pharmacy Services 10/28/19 01-19-80 02-19-74 03-19-73 08-19-82 09-19-76
11-19-73
14-19-72 24-19-74 27-19-74 30-19-72 31-19-79 32-19-72 33-19-76Ch. 1121 Prior Authorization of Ophthalmics, Antibiotics
(Formerly Ophthalmic Antibiotics)—Pharmacy Services10/28/19 01-19-71 02-19-65 03-19-64 08-19-73 09-19-67
11-19-64
14-19-63 24-19-65 27-19-65 30-19-63 31-19-70 32-19-63 33-19-67Ch. 1121 Prior Authorization of Ophthalmics, Antibiotic-Steroid Combinations (Formerly Ophthalmic Antibiotic-Steroid Combinations)—Pharmacy Services 10/28/19 01-19-70 02-19-64 03-19-63 08-19-72 09-19-66
11-19-63
14-19-62 24-19-64 27-19-64 30-19-62 31-19-69 32-19-62 33-19-66Ch. 1121 Prior Authorization of Otic Antibiotics
(Formerly Otic Antibiotic Preparations)—Pharmacy Services10/30/19 01-19-66 02-19-60 03-19-59 08-19-68 09-19-62
11-19-59
14-19-58 24-19-60 27-19-60 30-19-58 31-19-65 32-19-58 33-19-62Ch. 1121 Prior Authorization of Proton Pump Inhibitors (PPIs)—
Pharmacy Services10/30/19 01-19-93 02-19-87 03-19-86 08-19-95 09-19-89
11-19-86
14-19-85 24-19-87 27-19-87 30-19-85 31-19-92 32-19-85 33-19-89Ch. 1149 Medical Assistance Program Dental Fee Schedule and Dental Provider Handbook Update 10/30/19 27-19-17 Ch. 1121 Prior Authorization of Prenatal Vitamins—Pharmacy Services 10/30/19 01-19-92 02-19-86 03-19-85 08-19-94 09-19-88
11-19-85
14-19-84 24-19-86 27-19-86 30-19-84 31-19-91 32-19-84 33-19-88Ch. 1121 Prior Authorization of Steroids, Topical (Formerly Steroids, Topical Low; Steroids, Topical Medium; Steroids, Topical High; and Steroids, Topical Very High)—Pharmacy Services 10/30/19 01-19-90 02-19-84 03-19-83 08-19-92 09-19-86
11-19-83
14-19-82 24-19-84 27-19-84 30-19-82 31-19-89 32-19-82 33-19-86Ch. 1121 Prior Authorization of Skeletal Muscle Relaxants—
Pharmacy Services10/31/19 01-19-89 02-19-83 03-19-82 08-19-91 09-19-85
11-19-82
14-19-81 24-19-83 27-19-83 30-19-81 31-19-88 32-19-81 33-19-85Ch. 1121 Prior Authorization of Pancreatic Enzymes—Pharmacy Services 10/31/19 01-19-69 02-19-63 03-19-62 08-19-71 09-19-65
11-19-62
14-19-61 24-19-63 27-19-63 30-19-61 31-19-68 32-19-61 33-19-65Ch. 1121 Prior Authorization of Tetracyclines—Pharmacy Services 10/31/19 01-19-91 02-19-85 03-19-84 08-19-93 09-19-87
11-19-84
14-19-83 24-19-85 27-19-85 30-19-83 31-19-90 32-19-83 33-19-87Ch. 1149 Electronic Submission of Dental Prior Authorization, Dental Program Exception and Dental Benefit Limitation Requests 12/5/19 08-19-100 27-19-92 Ch. 1121 Prior Authorization of Antidepressants, Other—Pharmacy Services 12/5/19 01-19-98 02-19-92 03-19-91 08-19-101 09-19-94
11-19-91
14-19-90 24-19-93 27-19-93 30-19-90 31-19-98 32-19-90 33-19-95Ch. 1121 Prior Authorization of Opioid Dependence Treatments—
Pharmacy Services12/5/19 01-19-114 02-19-108 03-19-107 08-19-117 09-19-110 11-19-107 14-19-106 24-19-109 27-19-109 30-19-106 31-19-114 32-19-106 33-19-111 Ch. 1121 Prior Authorization of Antipsoriatics, Topical—Pharmacy Services 12/5/19 01-19-105 02-19-99 03-19-98 08-19-108 09-19-101 11-19-98
14-19-97 24-19-100 27-19-100 30-19-97 31-19-105 32-19-97 33-19-102Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—Pharmacy Services 12/5/19 01-19-112 02-19-106 03-19-105 08-19-115 09-19-108 11-19-105 14-19-104 24-19-107 27-19-107 30-19-104 31-19-112 32-19-104 33-19-109 Ch. 1121 Prior Authorization of Oncology Agents, Oral—Pharmacy Services 12/5/19 01-19-115 02-19-109 03-19-108 08-19-118 09-19-111 11-19-108 14-19-107 24-19-110 27-19-110 30-19-107 31-19-115 32-19-107 33-19-112 Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services12/5/19 01-19-103 02-19-97 03-19-96 08-19-106 09-19-99
11-19-96
14-19-95 24-19-98 27-19-98 30-19-95 31-19-103 32-19-95 33-19-100Ch. 1121 Prior Authorization of Dupixent (dupilumab)—Pharmacy Services 12/5/19 01-19-102 02-19-96 03-19-95 08-19-105 09-19-98
11-19-95
14-19-94 24-19-97 27-19-97 30-19-94 31-19-102 32-19-94 33-19-99Ch. 1121 Prior Authorization of Enzyme Replacements, Gaucher Disease—Pharmacy Services 12/5/19 01-19-111 02-19-105 03-19-104 08-19-114 09-19-107 11-19-104 14-19-103 24-19-106 27-19-106 30-19-103 31-19-111 32-19-103 33-19-108 Ch. 1121 Prior Authorization of Beta Blockers—Pharmacy Services 12/4/19 01-19-104 02-19-98 03-19-97 08-19-107 09-19-100 11-19-97
14-19-96 24-19-99 27-19-99 30-19-96 31-19-104 32-19-96 33-19-101Ch. 1121 Prior Authorization of Monocional Antibodies—Anti-IL, Anti-IgE (MABs—Anti-IL, Anti-IgE)—Pharmacy Services 12/5/19 01-19-107 02-19-101 03-19-100 08-19-110 09-19-103 11-19-100 14-19-99 24-19-102 27-19-102 30-19-99 31-19-107 32-19-99 33-19-104 Ch. 1121 Prior Authorization of Glucocorticoids, Oral—Pharmacy Services 12/5/19 01-19-110 02-19-104 03-19-103 08-19-113 09-19-106 11-19-103 14-19-102 24-19-105 27-19-105 30-19-102 31-19-110 32-19-102 33-19-107 Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 12/5/19 01-19-108 02-19-102 03-19-101 08-19-111 09-19-104 11-19-101 14-19-100 24-19-103 27-19-103 30-19-100 31-19-108 32-19-100 33-19-105 Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—
Pharmacy Services12/6/19 01-19-99 02-19-93 03-19-92 08-19-102 09-19-95
11-19-92
14-19-91 24-19-94 27-19-94 30-19-91 31-19-99 32-19-91 33-19-96Ch. 1121 Prior Authorization of Growth Hormones—Pharmacy Services 12/6/19 01-19-109 02-19-103 03-19-102 08-19-112 09-19-105 11-19-102 14-19-101 24-19-104 27-19-104 30-19-101 31-19-109 32-19-101 33-19-106 Ch. 1121 Prior Authorization of Analgesics, Opioid Short-Acting—
Pharmacy Services12/6/19 01-19-101 02-19-95 03-19-94 08-19-104 09-19-97
11-19-94
14-19-93 24-19-96 27-19-96 30-19-93 31-19-101 32-19-93 33-19-98Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled—Pharmacy Services 12/6/19 01-19-113 02-19-107 03-19-106 08-19-116 09-19-109 11-19-106 14-19-105 24-19-108 27-19-108 30-19-105 31-19-113 32-19-105 33-19-110 Ch. 1121 Prior Authorization of Macular Degeneration Agents—
Pharmacy Services12/6/19 01-19-116 02-19-110 03-19-109 08-19-119 09-19-112 11-19-109 14-19-108 24-19-111 27-19-111 30-19-108 31-19-116 32-19-108 33-19-113 Ch. 1121 Prior Authorization of Antimigraine Agents, Other—
Pharmacy Services12/6/19 01-19-106 02-19-100 03-19-99 08-19-109 09-19-102 11-19-99
14-19-98 24-19-101 27-19-101 30-19-98 31-19-106 32-19-98 33-19-103Ch. 1121 Prior Authorization of Anti-Allergens, Oral—Pharmacy Services 12/6/19 01-19-100 02-19-94 03-19-93 08-19-103 09-19-96
11-19-93
14-19-92 24-19-95 27-19-95 30-19-92 31-19-100 32-19-92 33-19-97Ch. 1126 1163 Billing for Inpatient Hospital and Short Procedure Unit Services When a MA Beneficiary is Directly Admitted from Observation 12/10/19 01-19-14 Ch. 1126 1150
1163Place of Service Review and Updates to Surgical Services 12/31/19 99-19-07 2020 Ch. 2600 2800
3270
3280
3290
3800
5310
6400
6600Medical Marijuana and State Licensure of Facilities and Agencies 1/2/20 01-20-03 02-20-01 03-20-01 05-20-01 06-20-01 34-20-01 47-20-01 56-20-01 Ch. 1150 1163
1243Addition of Coronavirus Laboratory Test Codes to the MA Program Fee Schedule 5/1/20 01-20-05 08-20-09 09-20-04 28-20-01 31-20-04 33-20-02 Ch. 1150 1123 Addition of the Multi-Function Ventilator to the Medical Assistance Program Fee Schedule 5/1/20 09-20-06 10-20-03 14-20-02 24-20-01 25-20-01 31-20-06 Ch. 1101 1150 COVID-19 Testing and Related Treatment Exempt from MA Copayment Requirements 5/1/20 99-20-05 Ch. 1123 1249 Home Health Services, Medical Supplies, Equipment and Appliances Prescribed by Non-physician Practitioners 5/1/20 09-20-05 10-20-02 14-20-01 31-20-05 33-20-03 Ch. 1101 1150
1163
1243ICD-10-CM Official Coding Guidelines Related to COVID-19 5/20/20 99-20-06 Ch. 1101 1150 2020 Healthcare Common Procedure Coding System Updates 5/26/20 99-20-02 Ch. 1241 Pennsylvania's Early and Periodic ScreeningDiagnosis and Treatment (EPSDT) Program Periodicity Schedule 5/26/20 99-20-04 Ch. 1241 Childhood Nutrition and Weight Management Services 5/26/20 01-20-06 08-20-08 09-20-03 23-20-01 31-20-03 Ch. 1101 1121 Pharmacy Services for Medical Assistance Beneficiaries Related to the COVID-19 Public Health Emergency 5/27/20 01-20-07 02-20-02 03-20-02 08-20-10 09-20-07
11-20-01
14-20-03 24-20-03 27-20-04 30-20-01 31-20-07 32-20-01 33-20-04Ch. 1101 1150
1249Implementation of Electronic Visit Verification in the FFS and Physical Health Managed Care Delivery Systems 6/11/20 05-20-02 07-20-02 Ch. 1101 1150 ''Payment in Full'' and Personal Protective Equipment 6/12/20 99-20-07 Ch. 1151 1163 Updates to the Procedures for Presumptive Eligibility as Determined by Hospitals 6/18/20 01-20-04 Ch. 1126 1129
1144
1221Addition of Opioid Use Disorder Centers of Excellence Provider Specialty 7/1/20 01-20-08
08-20-11
11-20-02
19-20-01 21-20-01 31-20-08Ch. 1101 1150
1249Electronic Visit Verification for Personal Care Services Provided in the Fee-for-Service Delivery System 8/26/20 05-20-03 Ch. 1121 Specialty Pharmacy Drug Program Preferred Specialty Pharmacy Providers—Pharmacy Services 9/9/20 01-20-09 02-20-03 03-20-03 08-20-12 09-20-08
11-20-03
14-20-04 24-20-04 27-20-05 30-20-02 31-20-09 32-20-02 33-20-05Ch. 1153 1129 Behavioral Health Group Therapy Provided in the Federally Qualified Health Center and Rural Health Clinic Settings 9/15/20 08-20-03 Ch. 1147 1129 Vision Services Provided in the Federally Qualified Health Center and Rural Health Clinic Settings 9/15/20 08-20-04 Ch. 1101 1150 School-Based ACCESS Program Provider Handbook 9/22/20 35-20-01 Ch. 1101 1121
1150
1243COVID-19 Specimen Collection and Testing at Pharmacies 10/1/20 24-20-02 Ch.1121 Prior Authorization of Analgesics, Non-Opioid Barbiturate Combinations—Pharmacy Services 11/6/20 01-20-11
02-20-04 03-20-04 08-20-14 09-20-10
11-20-04
14-20-05 24-20-05 27-20-06 30-20-03
31-20-11
32-20-03 33-20-07Ch. 1121 Prior Authorization of Analgesics, Opioid Long-Acting—
Pharmacy Services11/6/20 01-20-12 02-20-05 03-20-05 08-20-15
09-20-11
11-20-05
14-20-06 24-20-06 27-20-07 30-20-04 31-20-12 32-20-04 33-20-08Ch. 1121 Prior Authorization of Analgesics, Opioid Short-Acting—
Pharmacy Services11/6/20 01-20-13 02-20-06 03-20-06 08-20-16 09-20-12
11-20-06
14-20-07 24-20-07 27-20-08 30-20-05 31-20-13 32-20-05 33-20-09Ch. 1121 Prior Authorization of Bone Density Regulators—
Pharmacy Services11/6/20 01-20-14 02-20-07 03-20-07 08-20-17 09-20-13
11-20-07
14-20-08 24-20-08 27-20-09 30-20-06 31-20-14 32-20-06 33-20-10Ch. 1121 Prior Authorization of COPD Agents—Pharmacy Services 11/6/20 01-20-15 02-20-08 03-20-08 08-20-18 09-20-14
11-20-08
14-20-09 24-20-09 27-20-10 30-20-07 31-20-15 32-20-07
33-20-11Ch. 1121 Prior Authorization of Estrogens—Pharmacy Services 11/6/20 01-20-16 02-20-09 03-20-09 08-20-19 09-20-15
11-20-09
14-20-10 24-20-10
27-20-11
30-20-08 31-20-16 32-20-08 33-20-12Ch. 1121 Prior Authorization of H. Pylori Treatments—
Pharmacy Services BY Sally11/6/20 01-20-22 02-20-15 03-20-15 08-20-25 09-20-21
11-20-15
14-20-16 24-20-16 27-20-17 30-20-14 31-20-22 32-20-14 33-20-18Ch. 1121 Prior Authorization of Androgenic Agents—Pharmacy Services 11/9/20 01-20-17 02-20-10 03-20-10 08-20-20 09-20-16
11-20-10
14-20-11
24-20-11
27-20-12 30-20-09 31-20-17 32-20-09 33-20-13Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 11/9/20 01-20-18
02-20-11
03-20-11
08-20-21 09-20-17
11-20-11
14-20-12 24-20-12 27-20-13 30-20-10 31-20-18 32-20-10 33-20-14Ch. 1121 Prior Authorization of Antidepressants, Other—Pharmacy Services 11/9/20 01-20-19 02-20-12 03-20-12 08-20-22 09-20-18
11-20-12
14-20-13 24-20-13 27-20-14
30-20-11
31-20-19
32-20-11
33-20-15Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 11/9/20 01-20-20 02-20-13 03-20-13 08-20-23 09-20-19
11-20-13
14-20-14 24-20-14 27-20-15 30-20-12 31-20-20 32-20-12 33-20-16Ch. 1121 Prior Authorization of Hematopoietic Mixtures
(Formerly Iron, Oral)—Pharmacy Services11/9/20 01-20-23 02-20-16 03-20-16 08-20-26 09-20-22
11-20-16
14-20-17 24-20-17 27-20-18 30-20-15 31-20-23 32-20-15 33-20-19Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 11/9/20 01-20-24 02-20-17 03-20-17 08-20-27 09-20-23
11-20-17
14-20-18 24-20-18 27-20-19 30-20-16 31-20-24 32-20-16 33-20-20Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—Pharmacy Services 11/9/20 01-20-25 02-20-18 03-20-18 08-20-28 09-20-24
11-20-18
14-20-19 24-20-40 27-20-20 30-20-17 31-20-25 32-20-17 33-20-21Ch. 1121 Prior Authorization of HIV/AIDS Antiretrovirals—
Pharmacy Services11/10/20 01-20-26 02-20-19 03-20-19 08-20-29 09-20-25
11-20-19
14-20-20 24-20-19 27-20-21 30-20-18 31-20-26 32-20-18 33-20-22Ch. 1121 Prior Authorization of Hypoglycemia Treatments—
Pharmacy Services11/10/20 01-20-27 02-20-20 03-20-20 08-20-30 09-20-26
11-20-20
14-20-21 24-20-20 27-20-22 30-20-19 31-20-27 32-20-19 33-20-23Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—
Pharmacy Services11/10/20 01-20-28 02-20-21 03-20-21 08-20-31 09-20-27
11-20-21
14-20-22 24-20-21 27-20-23 30-20-20 31-20-28 32-20-20 33-20-24Ch. 1121 Prior Authorization of Hypoglycemics, Incretin Mimetics/
Enhancers—Pharmacy Services11/10/20 01-20-29 02-20-22 03-20-22 08-20-32 09-20-28
11-20-22
14-20-23 24-20-22 27-20-24 30-20-21 31-20-29 32-20-21 33-20-25Ch. 1121 Prior Authorization of Hypoglycemics, TZDs—Pharmacy Services 11/10/20 01-20-30 02-20-23 03-20-23 08-20-33 09-20-29
11-20-23
14-20-24 24-20-23 27-20-25 30-20-22 31-20-30 32-20-22 33-20-26Ch. 1121 Prior Authorization of Idiopathic Pulmonary Fibrosis (IPF) Agents—Pharmacy Services 11/10/20 01-20-31 02-20-24 03-20-24 08-20-34 09-20-30
11-20-24
14-20-25 24-20-24 27-20-26 30-20-23 31-20-31 32-20-23 33-20-27Ch. 1121 Prior Authorization of Intra-Articular Hyaluronates—Pharmacy Services 11/10/20 01-20-32 02-20-25 03-20-25 08-20-35 09-20-31
11-20-25
14-20-26 24-20-25 27-20-27 30-20-24 31-20-32 32-20-24 33-20-28Ch. 1101 1241 2020 Recommended Child and Adolescent Immunization Schedule 11/12/20 99-20-03 Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 11/12/20 01-20-33 02-20-26 03-20-26 08-20-36 09-20-32
11-20-26
14-20-27 24-20-26 27-20-28 30-20-25 31-20-33 32-20-25 33-20-29Ch. 1121 Prior Authorization of Migraine Acute Treatment Agents
(formerly Antimigraine Agents, Triptans)—Pharmacy Services11/12/20 01-20-34 02-20-27 03-20-27 08-20-37 09-20-33
11-20-27
14-20-28 24-20-27 27-20-29 30-20-26 31-20-34 32-20-26 33-20-30Ch. 1121 Prior Authorization of Migraine Prevention Agents
(formerly Antimigraine Agents, Other)—Pharmacy Services11/12/20 01-20-35 02-20-28 03-20-28 08-20-38 09-20-34
11-20-28
14-20-29 24-20-28 27-20-30 30-20-27 31-20-35 32-20-27 33-20-31Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services11/12/20 01-20-36 02-20-29 03-20-29 08-20-39 09-20-35
11-20-29
14-20-30 24-20-29 27-20-31 30-20-28 31-20-36 32-20-28 33-20-32Ch. 1121 Prior Authorization of NSAIDs—Pharmacy Services 11/12/20 01-20-37 02-20-30 03-20-30 08-20-40 09-20-36
11-20-30
14-20-31 24-20-30 27-20-32 30-20-29 31-20-37 32-20-29 33-20-33Ch. 1121 Prior Authorization of Opioid Dependence Treatments—
Pharmacy Services11/13/20 01-20-38 02-20-31 03-20-31 08-20-41 09-20-37
11-20-31
14-20-32 24-20-31 27-20-33 30-20-30 31-20-38 32-20-30 33-20-34Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—Pharmacy Services 11/13/20 01-20-39 02-20-32 03-20-32 08-20-42 09-20-38
11-20-32
14-20-33 24-20-32 27-20-34 30-20-31 31-20-39 32-20-31 33-20-35Ch. 1121 Prior Authorization of Progestational Agents—Pharmacy Services 11/13/20 01-20-40 02-20-33 03-20-33 08-20-43 09-20-39
11-20-33
14-20-34 24-20-33 27-20-35 30-20-32 31-20-40 32-20-32 33-20-36Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 11/13/20 01-20-41 02-20-34 03-20-34 08-20-44 09-20-40
11-20-34
14-20-35 24-20-34 27-20-36 30-20-33 31-20-41 32-20-33 33-20-37Ch. 1121 Prior Authorization of Sickle Cell Agents—Pharmacy Services 11/16/20 01-20-42 02-20-35 03-20-35 08-20-45 09-20-41
11-20-35
14-20-36 24-20-35 27-20-37 30-20-34 31-20-42 32-20-34 33-20-38Ch. 1121 Statewide Preferred Drug List (PDL) Implementation—
Pharmacy Services11/16/20 01-20-43 02-20-36 03-20-36 08-20-46 09-20-42
11-20-36
14-20-37 24-20-36 27-20-38 30-20-35 31-20-43 32-20-35 33-20-39Ch. 1121 Prior Authorization of Stimulants and Related Agents—
Pharmacy Services11/16/20 01-20-44 02-20-37 03-20-37 08-20-47 09-20-43
11-20-37
14-20-38 24-20-37 27-20-39 30-20-36 31-20-44 32-20-36 33-20-40Ch. 1121 Prior Authorization of Synagis (palivizumab)—Pharmacy Services 11/16/20 01-20-45 02-20-38 03-20-38 08-20-48 09-20-44
11-20-38
14-20-39 24-20-38 27-20-40 30-20-37 31-20-45 32-20-37 33-20-41Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services11/24/20 01-20-47 02-20-40 03-20-40 08-20-50 09-20-46
11-20-40
14-20-41 24-20-41 27-20-42 30-20-39 31-20-47 32-20-39 33-20-43Ch. 1121 Prior Authorization of Tysabri (natalizumab)—Pharmacy Services 11/24/20 01-20-48 02-20-41 03-20-41 08-20-51 09-20-47
11-20-41
14-20-42 24-20-42 27-20-43 30-20-40 31-20-48 32-20-40 33-20-44Ch. 1150 1149 Medical Assistance Program Dental Fee Schedule Update 12/2/20 27-20-01 Ch. 1121 Prior Authorization of Cystic Fibrosis Transmembrane Regulator (CFTR) Modulators—Pharmacy Services 12/14/20 01-20-49 02-20-42 03-20-42 08-20-52 09-20-48
11-20-42
14-20-43 24-20-43 27-20-44 30-20-41 31-20-49 32-20-41 33-20-45Ch. 1121 Prior Authorization of Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides—Pharmacy Services 12/14/20 01-20-55 02-20-48 03-20-48 08-20-58 09-20-54
11-20-48
14-20-49 24-20-49 27-20-50 30-20-47 31-20-55 32-20-47 33-20-51Ch. 1121 Prior Authorization of Evrysdi (risdiplam)—Pharmacy Services 12/14/20 01-20-56 02-20-49 03-20-49 08-20-59 09-20-55
11-20-49
14-20-50 24-20-50 27-20-51 30-20-48 31-20-56 32-20-48 33-20-52Ch. 1121 Prior Authorization of Palforzia [peanut (Arachis hypogaea) allergen powder]—Pharmacy Services 12/14/20 01-20-57 02-20-50 03-20-50 08-20-60 09-20-56
11-20-50
14-20-51 24-20-51 27-20-52 30-20-49 31-20-57 32-20-49 33-20-53Ch. 1121 Prior Authorization of Xyrem (sodium oxybate)/Xywav (calcium, magnesium, potassium, and sodium oxybates)—Pharmacy Services 12/14/20 01-20-58 02-20-51 03-20-51 08-20-61 09-20-57
11-20-51
14-20-52 24-20-52 27-20-53 30-20-50 31-20-58 32-20-50 33-20-54Ch. 1121 Prior Authorization of Crysvita (burosumab)—Pharmacy Services 12/15/20 01-20-50 02-20-43 03-20-43 08-20-53 09-20-49
11-20-43
14-20-44 24-20-44 27-20-45 30-20-42 31-20-50 32-20-42 33-20-46Ch. 1121 Prior Authorization of Complement Inhibitors—Pharmacy Services 12/15/20 01-20-51 02-20-44 03-20-44 08-20-54 09-20-50
11-20-44
14-20-45 24-20-45 27-20-46 30-20-43 31-20-51 32-20-43 33-20-47Ch. 1121 Prior Authorization of Corlanor (ivabradine)—Pharmacy Services 12/15/20 01-20-52 02-20-45 03-20-45 08-20-55 09-20-51
11-20-45
14-20-46 24-20-46 27-20-47 30-20-44 31-20-52 32-20-44 33-20-48Ch. 1121 Prior Authorization of Spinraza (nusinersen)—Pharmacy Services 12/15/20 01-20-53 02-20-49 03-20-46 08-20-56 09-20-52
11-20-46
14-20-47 24-20-47 27-20-48 30-20-45 31-20-53 32-20-45 33-20-49Ch. 1121 Prior Authorization of Tepezza (teprotumumab)—
Pharmacy Services12/15/20 01-20-54 02-20-47 03-20-47 08-20-57 09-20-53
11-20-47
14-20-48 24-20-48 27-20-49 30-20-46 31-20-54 32-20-46 33-20-50Ch. 1101 1150
1121Addition to the Medical Assistance Program Fee Schedule for Administration of SARS-CoV-2 Vaccines 12/24/20 01-20-59 08-20-62 09-20-58 31-20-59 33-20-55 Ch.1101 1150
1121SARS-CoV-2 Vaccine Administration by Pharmacists 12/30/20 01-20-60 02-20-52 03-20-52 08-20-63 09-20-59
11-20-52
14-20-53 24-20-53 27-20-54 30-20-51 31-20-60 32-20-51 33-20-562021 Ch. 1101 1150
1121SARS-CoV-2 Vaccine Updates 1/26/21 01-20-62 08-20-65 09-20-60 24-20-54 31-20-62 33-20-57 Ch. 1101 1150
1121Administration of SARS-CoV-2 Vaccine Manufactured by Janssen Biotech, Inc. 3/12/21 01-21-01 08-21-02 09-21-01 24-21-01 31-21-01 33-21-01 Ch. 1150 1121 Updates to the Medical Assistance Program Fee Schedule for Administration of SARS-CoV-2 Monoclonal Antibody Therapy 3/22/21 01-21-02 08-21-03 31-21-02 Ch. 1101 1150 Restoration of Provider Revalidation Requirements 3/23/21 99-21-01 Ch. 1101 1150
1121Addition to the Medical Assistance Program Fee Schedule for Administration of SARS-CoV-2 Monoclonal Antibody Therapy 3/25/21 01-20-61 08-20-64 31-20-61 Ch. 1149 Dental Benefit Limit Exception Process Update 4/15/21 08-21-01 27-21-01 Ch. 1150 1121 Fee Increase for the Administration of SARS-CoV-2 Vaccines 4/19/21 01-21-03 08-21-04 09-21-02 24-21-02 30-21-01 31-21-03 33-21-02 Ch. 1101 1150 Reinstatement of Prior Authorization Requirements for Certain Services 4/30/21 99-21-03 Ch. 1101 1150
1243Addition of COVID-19 Antigen Laboratory Test Codes to the MA Program Fee Schedule 5/18/21 01-20-10 08-20-13 09-20-09 28-20-02 31-20-10 33-20-06
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