[52 Pa.B. 4497]
[Saturday, August 6, 2022]
[Continued from previous Web Page] (Editor's Note: This document continues from Part III which begins at 52 Pa.B. 4629 (August 6, 2022).)
Year Code
CitationSubject Date Issued Bulletin Number Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 01/20/14 01-14-05
09-14-03
27-14-02
33-14-03
02-14-02
11-14-02
30-14-02
03-14-02
14-14-02
31-14-04
08-14-04
24-14-02
32-14-02Ch. 1121 Prior Authorization of Antipsoriatics Oral—Pharmacy Services 01/20/14 01-14-04
08-14-03
14-14-01
30-14-01
33-14-02
02-14-01
09-14-02
24-14-01
31-14-03
03-14-01
11-14-01
27-14-01
32-14-01Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 02/03/14 01-14-06
02-14-03
03-14-03
08-14-05
09-14-04
11-14-03
14-14-03
24-14-03
27-14-03
30-14-03
31-14-05
32-14-03
33-14-04Ch. 1121 Prior Authorization of Histamine II Receptor Blockers—Pharmacy Services 02/03/14 01-14-08
09-14-06
27-14-05
33-14-06
02-14-05
11-14-05
30-14-05
03-14-05
14-14-05
31-14-07
08-14-07
24-14-05
32-14-05Ch. 1121 Prior Authorization of Oncology Agents Oral—Pharmacy Services 02/03/14 01-14-11
09-14-09
27-14-08
33-14-09
02-14-08
11-14-08
30-14-08
03-14-08
14-14-08
31-14-10
08-14-10
24-14-08
32-14-08Ch. 1121 Prior Authorization of Epinephrine Self-Injected—Pharmacy Services 02/03/14 01-14-07
09-14-05
27-14-04
33-14-05
02-14-04
11-14-04
30-14-04
03-14-04
14-14-04
31-14-06
08-14-06
24-14-04
32-14-04Ch. 1121 Prior Authorization of Immunomodulators Topical—
Pharmacy Services02/03/14 01-14-09
09-14-07
27-14-06
33-14-07
02-14-06
11-14-06
30-14-06
03-14-06
14-14-06
31-14-08
08-14-08
24-14-06
32-14-06Ch. 1121 Prior Authorization of Iron Oral—Pharmacy Services 02/03/14 01-14-10
09-14-08
27-14-07 33-14-08
02-14-07
11-14-07
30-14-07
03-14-07
14-14-07
31-14-09
08-14-09
24-14-07
32-14-07Ch. 1121 Prior Authorization of Progestational Agents—Pharmacy Services 02/03/14 01-14-12
09-14-10
27-14-09
33-14-10
02-14-09
11-14-09
30-14-09
03-14-09
14-14-09
31-14-11
08-14-11
24-14-09
32-14-09Ch. 1150 Sample Review of Physicians Receiving Increased Fees for Select Primary Care Services 02/18/14 31-14-12 Ch. 1121 Specialty Pharmacy Drug Program—Updated List of Covered Drugs—Pharmacy Services 02/18/14 99-14-05 Ch. 1101 Provider Credentialing by the Pennsylvania Medical Assistance Program 02/27/14 99-14-02 Ch. 1101 Re-enrollment/Revalidation of Medical Assistance (MA) Providers 03/07/14 99-14-06 Ch. 1149 2014 Recommended Childhood and Adolescent Immunization Schedules 04/01/14 99-14-07 Ch. 1121 Prior Authorization of Prescriptions That Exceed Established Quantity Limits/Daily Dose Limits—Pharmacy Services 04/25/14 01-14-18
09-14-13
27-14-11
33-14-12
02-14-11
11-14-11
30-14-11
03-14-14
14-14-11
31-14-16
08-14-14
24-14-11
32-14-11Ch. 1121 Prior Authorization of Kalydeco. (ivacaftor)—Pharmacy Services 04/25/14 01-14-17
02-14-10
03-14-13
08-14-13
09-14-12
11-14-10
14-14-10
24-14-10
27-14-10
30-14-10
31-14-15
32-14-10
33-14-11Ch. 1243 Addition to the Medical Assistance Program Fee Schedule—Oncotype DX 05/06/14 01-14-16
08-14-12
09-14-11
28-14-01
31-14-14Ch. 1121 Prior Authorization of Analgesics Narcotic Long Acting—Pharmacy Services 05/30/14 01-14-24
09-14-19
27-14-17
33-14-18
02-14-16
11-14-16
30-14-16
03-14-19
14-14-16
31-14-22
08-14-20
24-14-16
32-14-16Ch. 1121 Prior Authorization of Immune Globulins—Pharmacy Services 05/30/14 01-14-25
09-14-20
27-14-18
33-14-19
02-14-17
11-14-17
30-14-17
03-14-20
14-14-17
31-14-23
08-14-21
24-14-17
32-14-17Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 05/30/14 01-14-22
09-14-17
27-14-15
33-14-16
02-14-14
11-14-14
30-14-14
03-14-17
14-14-14
31-14-20
08-14-18
24-14-14
32-14-14Ch. 1121 Prior Authorization of Opiate Dependence Treatments—
Pharmacy Services05/30/14 01-14-21
09-14-16
27-14-14
33-14-15
02-14-13
11-14-13
30-14-13
03-14-16
14-14-13
31-14-19
08-14-17
24-14-13
32-14-13Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and
Type B)—Pharmacy Services05/30/14 01-14-23
09-14-18
27-14-16
33-14-17
02-14-15
11-14-15
30-14-15
03-14-18
14-14-15
31-14-21
08-14-19
24-14-15
32-14-15Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 05/30/14 01-14-20
09-14-15
27-14-13
33-14-14
02-14-12
11-14-12
30-14-12
03-14-15
14-14-12
31-14-18
08-14-16
24-14-12
32-14-12Ch. 1101 2014 HCPCS Updates and Other Procedure Code Changes 06/13/14 99-14-04 Ch. 1121 Preferred Drug List (PDL) Updated July 22, 2014—
Pharmacy Services07/07/14 01-14-26
09-14-21
27-14-19
33-14-20
02-14-18
11-14-18
30-14-18
03-14-21
14-14-18
31-14-24
08-14-22
24-14-18
32-14-18Ch. 1141
1150ACA Primary Care Services 2014 Fee Schedule 07/07/14 31-14-13 Ch. 1121 Prior Authorization of Hypoglycemic, Alpha-Glucosidase Inhibitors—Pharmacy Services 07/25/14 01-14-33
09-14-28
27-14-26
33-14-27
02-14-25
11-14-25
30-14-25
03-14-28
14-14-25
31-14-31
08-14-29
24-14-25
32-14-25Ch. 1121 Prior Authorization of Hypoglycemics, Metformins—
Pharmacy Services07/25/14 01-14-34
02-14-26
03-14-29
08-14-30
09-14-29
11-14-26
14-14-26
24-14-26
27-14-27
30-14-26
31-14-32
32-14-26
33-14-28Ch. 1121 Prior Authorization of Hypoglycemics, Sulfonylureas—
Pharmacy Services07/25/14 01-14-35
02-14-27
03-14-30
08-14-31
09-14-30
11-14-27
14-14-27
24-14-27
27-14-28
30-14-27
31-14-33
32-14-27
33-14-29Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—Pharmacy Services 07/25/14 01-14-36
02-14-28
03-14-31
08-14-32
09-14-31
11-14-28
14-14-28
24-14-28
27-14-29
30-14-28
31-14-34
32-14-28
33-14-30Ch. 1121 Prior Authorization of Antiparasitics, Topical—Pharmacy Services 07/25/14 01-14-31
09-14-26
27-14-24
33-14-25
02-14-23
11-14-23
30-14-23
03-14-26
14-14-23
31-14-29
08-14-27
24-14-23
32-14-23Ch. 1121 Prior Authorization of Antimigraine Agents, Other—
Pharmacy Services07/25/14 01-14-29
09-14-24
27-14-22
33-14-23
02-14-21
11-14-21
30-14-21
03-14-24
14-14-21
31-14-27
08-14-25
24-14-21
32-14-21Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 07/25/14 01-14-28
02-14-20
03-14-23
08-14-24
09-14-23
11-14-20
14-14-20
24-14-20
27-14-21
30-14-20
31-14-26
32-14-20
33-14-22Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 07/25/14 01-14-38
02-14-30
03-14-33
08-14-34
09-14-33
11-14-30
14-14-30
24-14-30
27-14-31
30-14-30
31-14-36
32-14-30
33-14-32Ch. 1121 Prior Authorization of Nitrofuran Derivatives—Pharmacy Services 07/25/14 01-14-37
02-14-29
03-14-32
08-14-33
09-14-32
11-14-29
14-14-29
24-14-29
27-14-30
30-14-29
31-14-35
32-14-29
33-14-31Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—Pharmacy Services 07/25/14 01-14-32
09-14-27
27-14-25
33-14-26
02-14-24
11-14-24
30-14-24
03-14-27
14-14-24
31-14-30
08-14-28
24-14-24
32-14-24Ch. 1121 Prior Authorization of Thyroid Hormones—Pharmacy Services 07/25/14 01-14-39
02-14-31
03-14-34
08-14-35
09-14-34
11-14-31
14-14-31
24-14-31
27-14-32
30-14-31
31-14-37
32-14-31
33-14-33Ch. 1121 Prior Authorization of Acne Agents, Oral—Pharmacy Services 08/05/14 01-14-27
09-14-22
27-14-20
33-14-21
02-14-19
11-14-19
30-14-19
03-14-22
14-14-19
31-14-25
08-14-23
24-14-19
32-14-19Ch. 1121 Prior Authorization of Ulcerative Colitis Agents—Pharmacy Services 08/05/14 01-14-40
09-14-35
27-14-33
33-14-34
02-14-32
11-14-32
30-14-32
03-14-35
14-14-32
31-14-38
08-14-36
24-14-32
32-14-32Ch. 1121 Prior Authorization of Antimigraine Agents, Triptans—
Pharmacy Services08/05/14 01-14-30
09-14-25
27-14-23
33-14-24
02-14-22
11-14-22
30-14-22
03-14-25
14-14-22
31-14-28
08-14-26
24-14-22
32-14-22Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 08/11/14 01-14-41
09-14-36
27-14-34
33-14-35
02-14-33
11-14-33
30-14-33
03-14-36
14-14-33
31-14-39
08-14-37
24-14-33
32-14-33Ch. 1101 Implementation of National Correct Coding Initiative Related Modifiers 09/12/14 99-14-08 Ch. 1149
1150New Procedure Code for Dental Services 09/27/14 27-14-12 Ch. 1101
1150Presumptive Eligibility for Pregnant Women 10/24/14 01-14-19
08-14-15
09-14-14
31-14-17
33-14-13
47-14-02Ch. 1101 Implementation of Healthy Pennsylvania 11/04/14 99-14-09 Ch. 1101
1141
1150
1221Advanced Radiologic Imaging Services 11/21/14 01-14-42 Ch. 1123 Revisions to Prior Authorization Requirements for Apnea Monitors 12/09/14 24-14-34
25-14-01Ch. 1101 Healthy PA Benefit Plans 12/12/14 99-14-10 Ch. 1141
1150Medical Assistance Fees for Primary Care Services 12/20/14 31-14-40 Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/29/14 01-14-53
02-14-43
03-14-46
08-14-47
09-14-46
11-14-43
14-14-43
24-14-44
27-14-44
30-14-43
31-14-50
32-14-43
33-14-45Ch. 1121 Prior Authorization of Anti-Allergens, Oral—Pharmacy Services 12/29/14 01-14-47
09-14-40
27-14-38
33-14-39
02-14-37
11-14-37
30-14-37
03-14-40
14-14-37
31-14-44
08-14-41
24-14-38
32-14-37Ch. 1121 Prior Authorization of Rilutek (riluzole)—Pharmacy Services 12/29/14 01-14-51
02-14-41
03-14-44
08-14-45
09-14-44
11-14-41
14-14-41
24-14-42
27-14-42
30-14-41
31-14-48
32-14-41
33-14-43Ch. 1121 Prior Authorization of Compounded Prescriptions—
Pharmacy Services12/29/14 01-14-44
02-14-34
03-14-37
08-14-38
09-14-37
11-14-34
14-14-34
24-14-35
27-14-35
30-14-34
31-14-41
32-14-34
33-14-36Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services12/29/14 01-14-52
02-14-42
03-14-45
08-14-46
09-14-45
11-14-42
14-14-42
24-14-43
27-14-43
30-14-42
31-14-49
32-14-42
33-14-44Ch. 1121 Prior Authorization of Soliris (eculizumab)—Pharmacy Services 12/29/14 01-14-48
09-14-41
27-14-39
33-14-40
02-14-38
11-14-38
30-14-38
03-14-41
14-14-38
31-14-45
08-14-42
24-14-39
32-14-38Ch. 1121 Prior Authorization of Mozobil (Plerixafor)—Pharmacy Services 12/29/14 01-14-49
09-14-42
27-14-40
33-14-41
02-14-39
11-14-39
30-14-39
03-14-42
14-14-39
31-14-46
08-14-43
24-14-40
32-14-39Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—Pharmacy Services 12/29/14 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 Services 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 Services 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 Services05/11/15 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 Services 05/11/15 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 Services 06/25/15 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 Services 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 Services07/13/15 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 Services 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 Services 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 Services 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 33-15-34Ch. 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 Services11/13/15 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 Services 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 Services 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 Services 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 Services11/30/15 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 Services11/30/15 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 Services 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 Services 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 Services01/06/16 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 Services 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 Services 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 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 33-16-16Ch. 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 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 33-16-25Ch. 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 33-16-23Ch. 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 Services01/04/17 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 Services 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 Services 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 Services 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 Services 06/07/17 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 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 33-17-31Ch. 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 Services08/08/17 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 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 33-17-35Ch. 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 Services 12/27/17 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 Services 07/23/18 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 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 55-18-01Ch. 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 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 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 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 33-19-09Ch. 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 Services 8/8/19 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 Services 8/8/19 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 Services 8/20/19 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 Services 9/5/19 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 Services 10/25/19 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 Services 10/28/19 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 Services 10/28/19 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 Services 10/30/19 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 33-19-111Ch. 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 33-19-109Ch. 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 33-19-112Ch. 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 33-19-108Ch. 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 33-19-104Ch. 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 33-19-107Ch. 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 33-19-105Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—Pharmacy Services 12/6/19 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 33-19-106Ch. 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 33-19-110Ch. 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 33-19-113Ch. 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 Screening Diagnosis 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 Services 11/6/20 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 Sally 11/6/20 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 Services 11/9/20 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 Services 11/10/20 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 Services 11/10/20 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 Services 11/10/20 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 Services11/10/20 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 Services 11/12/20 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 Services 11/12/20 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 Services 11/12/20 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 Services12/14/20 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 Services 12/15/20 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 Ch. 1101 1241 Pennsylvania's Early and Periodic Screening Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 6/24/21 99-21-02 Ch. 1241 2021 Recommended Child and Adolescent Immunization Schedule 6/28/21 99-21-05 Ch. 1101 1150 Medical Assistance (MA) Program Fee Schedule Revisions 6/30/21 99-20-09 Ch. 1150
1121
1123Medical Assistance Program Fee Increase for Disposable Gloves 7/6/21 24-21-05 25-21-02 Ch. 1150 1121 SARS-CoV-2 Vaccine Administration for Beneficiaries who are Homebound 7/29/21 01-21-04 05-21-01 08-21-05 09-21-03 24-21-03 26-21-01 30-21-02 31-21-04 33-21-03 Ch. 1101
1150
1121Expansion of Providers for the Administration of SARS-CoV-2 Vaccines and Monoclonal Antibody Therapy 7/29/21 01-21-08 05-21-03 08-21-09 09-21-07 24-21-07 26-21-02 30-21-04 31-21-09 33-21-08 Ch. 1101
1150
1121Corrected—Expansion of Providers for the Administration of SARS-CoV-2 Vaccines and Monoclonal Antibody Therapy 7/30/21 01-21-11
05-21-05
08-21-12
09-21-09
11-21-01
24-21-08 26-21-03 30-21-06 31-21-12 33-21-09Ch. 1101 1150 2021 Healthcare Common Procedure Coding System (HCPCS) Updates, Fee Adjustments and Other Procedure Code Changes 8/20/21 99-21-04 Ch. 1101
1150
1121Administration of a Third Dose of SARS-CoV-2 Vaccines Manufactured by Pfizer, Inc. and Moderna, Inc. 9/1/21 01-21-12 05-21-06 08-21-13 09-21-10
11-21-02
24-21-09 26-21-04 30-21-07 31-21-13 33-21-10Ch. 1123 1150 Coverage of Home Accessibility Durable Medical Equipment and Procedure for Obtaining an 1150 Administrative Waiver in the Fee-for-Service Delivery System 9/21/21 09-21-04 10-21-01 14-21-01 24-21-04 25-21-01 31-21-05 33-21-04 Ch. 1150 1225 Updates to the Family Planning Services Program Fee Schedule 9/24/21 01-21-06 08-21-06 09-21-05 24-21-06 25-21-03 28-21-01 31-21-07 33-21-06 Ch. 1101 1150 Guidelines for the Delivery of Physical Health Services via Telemedicine 9/30/21 99-21-06 Ch. 1150 1129 Naloxone Distribution by Federally Qualified Health Centers and Rural Health Clinics 10/21/21 08-21-07 Ch. 1249 Updated Error Status Code Descriptions for Personal Care Services Subject to Electronic Visit Verification 10/22/21 05-21-04 07-21-01 54-21-02 59-21-02 00-21-03 Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 11/2/21 01-21-14 02-21-01 03-21-01 08-21-15 09-21-13
11-21-03
14-21-04
24-21-11
27-21-04 30-21-08 31-21-16 32-21-01 33-21-13Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—
Pharmacy Services11/2/21 01-21-15 02-21-02 03-21-02 08-21-16 09-21-14
11-21-04
14-21-05 24-21-12 27-21-05 30-21-09 31-21-17 32-21-02 33-21-14Ch. 1121 Prior Authorization of Antifungals, Topical—Pharmacy Services 11/2/21 01-21-16 02-21-03 03-21-03 08-21-17 09-21-15
11-21-05
14-21-06 24-21-13 27-21-06 30-21-10 31-21-18 32-21-03 33-21-15Ch. 1121 Prior Authorization of Antihemophilia Agents—Pharmacy Services 11/2/21 01-21-17 02-21-04 03-21-04 08-21-18 09-21-16
11-21-06
14-21-07 24-21-14 27-21-07
30-21-11
31-21-19 32-21-04 33-21-16Ch. 1121 Prior Authorization of Antihyperuricemics—Pharmacy Services 11/2/21 01-21-18 02-21-05 03-21-05 08-21-19 09-21-17
11-21-07
14-21-08 24-21-15 27-21-08 30-21-12 31-21-20 32-21-05 33-21-17Ch. 1121 Prior Authorization of Antiparasitics, Topical—Pharmacy Services 11/4/21 01-21-20 02-21-07 03-21-07 08-21-21 09-21-19
11-21-09
14-21-10 24-21-17 27-21-10 30-21-14 31-21-22 32-21-07 33-21-19Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 11/4/21 01-21-21 02-21-08 03-21-08 08-21-22 09-21-20
11-21-10
14-21-11
24-21-18
27-21-11
30-21-15
31-21-23 32-21-08 33-21-20Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 11/4/21 01-21-22 02-21-09 03-21-09 08-21-23 09-21-21
11-21-11
14-21-12 24-21-19 27-21-12 30-21-16 31-21-24 32-21-09 33-21-21Ch. 1121 Prior Authorization of Bladder Relaxant Preparations—
Pharmacy Services11/5/21 01-21-23 02-21-10 03-21-10 08-21-24 09-21-22
11-21-12
14-21-13 24-21-20 27-21-13 30-21-17 31-21-25 32-21-10 33-21-22Ch. 1121 Prior Authorization of Bone Density Regulators—Pharmacy Services 11/5/21 01-21-24
02-21-11
03-21-11
08-21-25
09-21-23
11-21-13
14-21-14 24-21-21 27-21-14 30-21-18 31-21-26
32-21-11
33-21-23Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—
Pharmacy Services11/5/21 01-21-26 02-21-13 03-21-13 08-21-28 09-21-25
11-21-15
14-21-16 24-21-23 27-21-17 30-21-20 31-21-28 32-21-13 33-21-25Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services11/5/21 01-21-28 02-21-15 03-21-15 08-21-30 09-21-27
11-21-17
14-21-18 24-21-25 27-21-19 30-21-22 31-21-30 32-21-25 33-21-27Ch. 1121 Prior Authorization of Dupixent (dupilumab)—Pharmacy Services 11/5/21 01-21-29 02-21-16 03-21-16 08-21-31 09-21-28
11-21-18
14-21-19 24-21-26 27-21-20 30-21-23 31-21-31 32-21-16 33-21-28Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and
Type B)—Pharmacy Services11/8/21 01-21-25 02-21-12 03-21-12 08-21-27 09-21-24
11-21-14
14-21-15 24-21-22 27-21-16 30-21-19 31-21-27 32-21-12 33-21-24Ch. 1121 Prior Authorization of Chronic Obstructive Pulmonary Disease (COPD) Agents—Pharmacy Services 11/8/21 01-21-27 02-21-14 03-21-14 08-21-29 09-21-26
11-21-16
14-21-17 24-21-24 27-21-18 30-21-21 31-21-29 32-21-14 33-21-26Ch. 1121 Prior Authorization of Erythropoiesis Stimulating Agents (ESAs)—Pharmacy Services 11/8/21 01-21-45 02-21-32 03-21-32 08-21-47 09-21-44
11-21-34
14-21-35 24-21-42 27-21-36 30-21-39 31-21-47 32-21-32 33-21-44Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—
Pharmacy Services11/8/21 01-21-46 02-21-33 03-21-33 08-21-48 09-21-45
11-21-35
14-21-36 24-21-43 27-21-37 30-21-40 31-21-48 32-21-33 33-21-45Ch. 1121 Prior Authorization of HIV/AIDS Antiretrovirals—Pharmacy Services 11/8/21 01-21-49 02-21-36 03-21-36 08-21-51 09-21-48
11-21-38
14-21-39 24-21-46 27-21-40 30-21-43 31-21-51 32-21-36 33-21-48Ch. 1121 Prior Authorization of Immunomodulators, Atopic Dermatitis—Pharmacy Services 11/10/21 01-21-30 02-21-17 03-21-17 08-21-32 09-21-29
11-21-19
14-21-20 24-21-27 27-21-21 30-21-24 31-21-32 32-21-17 33-21-29Ch. 1121 Prior Authorization of Migraine Acute Treatment Agents—
Pharmacy Services11/10/21 01-21-33 02-21-20 03-21-20 08-21-35 09-21-32
11-21-22
14-21-23 24-21-30 27-21-24 30-21-27 31-21-35 32-21-20 33-21-32Ch. 1121 Prior Authorization of Migraine Prevention Agents—
Pharmacy Services11/10/21 01-21-34 02-21-21 03-21-21 08-21-36 09-21-33
11-21-23
14-21-24 24-21-31 27-21-25 30-21-28 31-21-36 32-21-21 33-21-33Ch. 1121 Prior Authorization of Glucocorticoids, Inhaled—Pharmacy Services 11/10/21 01-21-47 02-21-34 03-21-34 08-21-49 09-21-46
11-21-36
14-21-37 24-21-44 27-21-38 30-21-41 31-21-49 32-21-34 33-21-46Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 11/10/21 01-21-48 02-21-35 03-21-35 08-21-50 09-21-47
11-21-37
14-21-38 24-21-45 27-21-39 30-21-42 31-21-50 32-21-35 33-21-47Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 11/12/21 01-21-31 02-21-18 03-21-18 08-21-33 09-21-30
11-21-20
14-21-21 24-21-28 27-21-22 30-21-25 31-21-33 32-21-18 33-21-30Ch. 1121 Prior Authorization of Monoclonal Antibodies (MABs)—
Anti-IL Anti-IgE—Pharmacy Services11/12/21 01-21-32 02-21-19 03-21-19 08-21-34 09-21-31
11-21-21
14-21-22 24-21-29 27-21-23 30-21-26 31-21-34 32-21-19 33-21-31Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—Pharmacy Services 11/12/21 01-21-35 02-21-22 03-21-22 08-21-37 09-21-34
11-21-24
14-21-25 24-21-32 27-21-26 30-21-29 31-21-37 32-21-22 33-21-34Ch. 1121 Prior Authorization of Opioid Dependence Treatments—
Pharmacy Services11/12/21 01-21-36 02-21-23 03-21-23 08-21-38 09-21-35
11-21-25
14-21-26 24-21-33 27-21-27 30-21-30 31-21-38 32-21-23 33-21-35Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—Pharmacy Services 11/12/21 01-21-37 02-21-24 03-21-24 08-21-39 09-21-36
11-21-26
14-21-27 24-21-34 27-21-28 30-21-31 31-21-39 32-21-24 33-21-36Ch. 1121 Prior Authorization of Pulmonary Hypertension Agents, Oral and Inhaled—Pharmacy Services 11/15/21 01-21-38 02-21-25 03-21-25 08-21-40 09-21-37
11-21-27
14-21-28 24-21-35 27-21-29 30-21-32 31-21-40 32-21-25 33-21-37Ch. 1121 Obsolete—Prior Authorization of Rilutek (riluzole)—
Pharmacy Services11/15/21 01-21-39 02-21-26 03-21-26 08-21-41 09-21-38
11-21-28
14-21-29 24-21-36 27-21-30 30-21-33 31-21-41 32-21-26 33-21-38Ch. 1121 Statewide Preferred Drug List (PDL) Implementation—
Pharmacy Services11/15/21 01-21-40 02-21-27 03-21-27 08-21-42 09-21-39
11-21-29
14-21-30 24-21-37 27-21-31 30-21-34 31-21-42 32-21-27 33-21-39Ch. 1121 Prior Authorization of Tysabri (natalizumab)—Pharmacy Services 11/15/21 01-21-41 02-21-28 03-21-28 08-21-43 09-21-40
11-21-30
14-21-31 24-21-38 27-21-32 30-21-35 31-21-43 32-21-28 33-21-40Ch. 1121 Prior Authorization of Ulcerative Colitis Agents—Pharmacy Services 11/15/21 01-21-42 02-21-29 03-21-29 08-21-44 09-21-41
11-21-31
14-21-32 24-21-39 27-21-33 30-21-36 31-21-44 32-21-29 33-21-41Ch. 1121 Prior Authorization of VMAT2 Inhibitors—Pharmacy Services 11/16/21 01-21-43 02-21-30 03-21-30 08-21-45 09-21-42
11-21-32
14-21-33 24-21-40 27-21-34 30-21-37 31-21-45 32-21-30 33-21-42Ch. 1121 Prior Authorization of Zeposia (ozanimod)—Pharmacy Services 11/16/21 01-21-44 02-21-31 03-21-31 08-21-46 09-21-43
11-21-33
14-21-34 24-21-41 27-21-35 30-21-38 31-21-46 32-21-31 33-21-43Ch. 1121 Prior Authorization of Growth Hormones—Pharmacy Services 11/17/21 01-21-52 02-21-37 03-21-37 08-21-54 09-21-51
11-21-40
14-21-40 24-21-48 27-21-41 30-21-45 31-21-54 32-21-37 33-21-51Ch. 1121 Prior Authorization of Immunosuppressives, Oral—
Pharmacy Services11/17/21 01-21-53 02-21-38 03-21-38 08-21-55 09-21-52
11-21-41
14-21-41 24-21-49 27-21-42 30-21-46 31-21-55 32-21-38 33-21-52Ch. 1121 Prior Authorization of Skeletal Muscle Relaxants—
Pharmacy Services11/17/21 01-21-54 02-21-39 03-21-39 08-21-56 09-21-53
11-21-42
14-21-42 24-21-50 27-21-43 30-21-47 31-21-56 32-21-39 33-21-53Ch. 1150 1149 2021 Medical Assistance Program Dental Fee Schedule Update 11/30/21 27-21-02 Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 12/16/21 01-21-56 02-21-40 03-21-40 08-21-58 09-21-55
11-21-44
14-21-43 24-21-52 27-21-44 30-21-49 31-21-58 32-21-41 33-21-54Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 12/16/21 01-21-57 02-21-41 03-21-41 08-21-59 09-21-56
11-21-45
14-21-44 24-21-53 27-21-45 30-21-50 31-21-59 32-21-42 33-21-55Ch. 1101
1150
1121Pediatric SARS-CoV-2 Vaccine Manufactured by Pfizer, Inc. 12/27/21 01-21-51 05-21-09 08-21-53 09-21-50
11-21-39
24-21-47
26-21-05 30-21-44 31-21-53 33-21-50Ch. 1101
1150
1187
1249Medical Assistance Program Fee Increases for Private Duty/Shift Nursing Services to MA Beneficiaries Under 21 Years of Age 12/27/21 05-21-10 16-21-02 Ch. 1101
1150
1121Administration of a Booster Dose of the SARS-CoV-2 Vaccines 12/28/21 01-21-55
05-21-11
08-21-57
09-21-54
11-21-43
24-21-51
26-21-06 30-21-48 31-21-57 33-21-40Ch.1121 Prior Authorization of HIV/AIDS Antiretrovirals—Pharmacy Services 12/28/21 01-21-58 02-21-42 03-21-42 08-21-60 09-21-57
11-21-46
14-21-47 24-21-54 27-21-46 30-21-51 31-21-60 32-21-43 33-21-56Ch.1121 Vaccine Administration by Pharmacists—Pharmacy Services 12/30/21 01-21-19 02-21-06 03-21-06 08-21-20 09-21-18
11-21-08
14-21-09 24-21-16 27-21-09 30-21-13 31-21-21 32-21-06 33-21-182022 Ch. 1150 1144 Billing Procedure Update for Certified Registered Nurse Practitioners and Physician Assistants 1/7/22 01-22-05 08-22-05 09-22-04 10-22-01 31-22-05 Ch.1121 Prior Authorization of Xyrem (sodium oxybate)/Xywav (calcium, magnesium, potassium, and sodium oxybates)—
Pharmacy Services1/11/22 01-22-04 02-22-02 03-22-02 08-22-04 09-22-03
11-22-03
14-22-02 24-22-02 27-22-02 30-22-02 31-22-04 32-22-02 33-22-03Ch.1121 Prior Authorization of Aduhelm (aducanumab)—Pharmacy Services 1/12/22 01-22-03 02-22-01 03-22-01 08-22-03 09-22-02
11-22-02
14-22-01 24-22-01 27-22-01 30-22-01 31-22-03 32-22-01 33-22-02Ch. 1101
1150
1121SARS-CoV-2 (COVID-19) Oral Antiviral Treatments with emergency use authorization (EUA) from the U.S. Food and Drug Administration (FDA) 1/25/22 01-22-06 02-22-03 03-22-03 08-22-06 09-22-05
11-22-04
14-22-03 24-22-03 27-22-03 30-22-03 31-22-06 32-22-03 33-22-04Ch. 1101 1123 At-Home Over-The-Counter COVID-19 Tests 2/1/22 24-21-55 Ch. 1121 Preferred Specialty Pharmacy Drug Program Provider—
Pharmacy Services2/9/22 01-22-08 02-22-04 03-22-04 08-22-08 09-22-07
11-22-05
14-22-04 24-22-04 27-22-04 30-22-04 31-22-08 32-22-04 33-22-06Ch. 1101 1223 Community-Based Care Management Services Provided by Centers of Excellence for Opioid Use Disorders (COEs) 2/14/22 01-22-02 08-22-02
11-22-01
19-22-01
21-22-01 31-22-02Ch. 1150
1121
1129Federally Qualified Health Center and Rural Health Clinic Payment for SARS-CoV-2 Vaccine Administration 2/24/22 08-20-66 Ch. 1101
1150
1121SARS-CoV-2 Monoclonal Antibody Product Updates 2/24/22 01-21-59 05-21-12 08-21-61 09-21-58 30-21-52 31-21-61 33-21-57 Ch. 1150 1121 Update to Age Limits for Payment for Administration of the Flucelvax® Quadrivalent Vaccine 3/7/22 01-21-60 08-21-62 09-21-59 31-21-62 33-21-58 Ch. 1121 MenQuadfi® and Vaxelis® Vaccines 3/21/22 01-21-13 08-21-14
09-21-11
31-21-14
33-21-11Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 3/22/22 01-22-09 02-22-05 03-22-05 08-22-09 09-22-08
11-22-06
14-22-05 24-22-05 27-22-05 30-22-05 31-22-09 32-22-05 33-22-07Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 3/22/22 01-22-10 02-22-06 03-22-06 08-22-10 09-22-09
11-22-07
14-22-06 24-22-06 27-22-06 30-22-06 31-22-10 32-22-06 33-22-08Ch. 1150 1243 Additions to the Medical Assistance Program Fee Schedule for Multiple Respiratory Pathogens Laboratory Tests 3/25/22 01-22-07 08-22-07 09-22-06 10-22-02 28-22-01 31-22-07 33-22-05 Ch. 1101 1140 Extension of Postpartum Coverage from 60 days to 12 Months 3/31/22 99-22-01 Ch. 1150 Additions to the Medical Assistance Fee Schedule for Personal Care Services Provided to Beneficiaries Under the Age of 21 4/18/22 05-22-01 07-22-01 Ch. 1101 1150 School-Based ACCESS Program Provider Handbook Mid-Year Update 5/2/22 35-22-01 Ch. 1101 Updates to Guidelines for the Delivery of Physical Health Services via Telemedicine 5/6/22 99-22-02 Ch. 1101
1150
1121Addition of Monoclonal Antibody Product Bebtelovimab to the MA Program Fee Schedule 5/9/22 01-22-11
05-22-03
08-22-11
09-22-10 10-22-03 30-22-07
31-22-11
33-22-09Ch. 1101 1241 2022 Recommended Child and Adolescent Immunization Schedule 5/12/22 99-22-03 Ch. 1101
1150
1121Third Dose of Pediatric SARS-CoV-2 Vaccine Manufactured by Pfizer, Inc. 6/3/22 01-22-16 05-22-05 08-22-17 09-22-15 10-22-07 24-22-10 26-22-02 30-22-09 31-22-16 33-22-14 Ch. 1101
1150
1121Addition to Medical Assistance Program Fee Schedule for Administration of Ready-to-Use SARS-CoV-2 Vaccine Manufactured by Pfizer, Inc. 6/3/22 01-22-17 05-22-06 08-22-18 09-22-16 10-22-08
24-22-11
26-22-03 30-22-10 31-22-17 33-22-15Ch. 1241 Updates to Blood Lead Reference Value and Environmental Lead Investigation (ELI) Provider Qualifications Requirements 6/6/22 01-22-13 08-22-14 09-22-12 31-22-13
33-22-11
55-22-01
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