[46 Pa.B. 5185]
[Saturday, August 20, 2016]
[Continued from previous Web Page]
Year Code Citation(s) Subject Date Issued Bulletin Number 2013 Ch. 1121 Prior Authorization of Antipsoriatics Topical—
Pharmacy Services1/7/13 01-13-01
09-13-01
27-13-01
33-13-01
02-13-01
11-13-01
30-13-01
03-13-01
14-13-01
31-13-01
08-13-01
24-13-01
32-13-01Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 1/7/13 01-13-02
09-13-02
27-13-02
33-13-02
02-13-02
11-13-02
30-13-02
03-13-02
14-13-02
31-13-02
08-13-02
24-13-02
32-13-02Ch. 1121 Prior Authorization of Diabetic Strips—Pharmacy Services 1/7/13 01-13-03
09-13-03
27-13-03
33-13-03
02-13-03
11-13-03
30-13-03
03-13-03
14-13-03
31-13-03
08-13-03
24-13-03
32-13-03Ch. 1121 Prior Authorization of Glucocorticoids Oral—Pharmacy Services 1/7/13 01-13-04
09-13-04
27-13-04
33-13-04
02-13-04
11-13-04
30-13-04
03-13-04
14-13-04
31-13-04
08-13-04
24-13-04
32-13-04Ch. 1121 Prior Authorization of Leukotriene Modifiers—Pharmacy Services 1/7/13 01-13-05
09-13-05
27-13-05
33-13-05
02-13-05
11-13-05
30-13-05
03-13-05
14-13-05
31-13-05
08-13-05
24-13-05
32-13-05Ch. 1121 Prior Authorization of Neuropathic Pain Agents (Formerly Myalgia and Neuropathy Agents)—
Pharmacy Services1/7/13 01-13-06
09-13-06
27-13-06
33-13-06
02-13-06
11-13-06
30-13-06
03-13-06
14-13-06
31-13-06
08-13-06
24-13-06
32-13-06Ch. 1121 Prior Authorization of Oncology Agents Breast Cancer—Pharmacy Services 1/7/13 01-13-07
08-13-07
14-13-07
32-13-07
02-13-07
09-13-07
24-13-07
30-13-07
03-13-07
11-13-07
27-13-07
31-13-07
33-13-07Ch. 1121 Prior Authorization of Smoking Cessation Products—
Pharmacy Services1/7/13 01-13-08
09-13-08
27-13-08
33-13-08
02-13-08
11-13-08
30-13-08
03-13-08
14-13-08
31-13-08
08-13-08
24-13-08
32-13-08Ch. 1121 Prior Authorization of Diabetic Meters—Pharmacy Services 1/7/13 01-13-09
09-13-09
27-13-09
33-13-09
02-13-09
11-13-09
30-13-09
03-13-09
14-13-09
31-13-09
08-13-09
24-13-09
32-13-09Ch. 1229 HealthChoices Physical Health Managed Care New East Zone Expansion 01/18/13 99-13-02 Ch. 1121 Preferred Drug List (PDL) Update January 15, 2013—
Pharmacy Services01/22/13 01-13-11
09-13-11
27-13-11
33-13-11
02-13-10
11-13-10
30-13-10
03-13-10
14-13-10
31-13-12
08-13-11
24-13-11
32-13-10Ch. 1150 Medical Assistance Program Fee Increase for Select Primary Care Services and Physician Attestation Form 01/22/13 31-13-11 Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 1/25/13 01-13-12
08-13-12
14-13-11
30-13-11
33-13-12
02-13-11
09-13-12
24-13-12
31-13-13
03-13-11
11-13-11
27-13-12
32-13-11Ch. 1150 Medical Assistance Program Fee Increase for Select Primary Care Services and Physician Attestation Form 01/22/13 31-13-11 Ch. 1101
Ch. 1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2013 for Eligible Professionals (EP) 2/1/13 08-13-10
09-13-10
27-13-10
31-13-10
33-13-10Ch. 1101
Ch. 1150Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2013 for Eligible Hospitals (EH) 2/1/13 01-13-10 Ch. 1101 Updated Procedures for Submitting the Deficit Reduction Act of 2005 Attestation Form 02/14/13 99-13-04 Ch. 1229 Continued Existence of the Fee-For-Service Delivery System in HealthChoices Zones and Enrollment of Breast and Cervical Cancer Prevention and Treatment (BCCPT) Recipients in HealthChoices 02/22/13 99-13-05 Ch. 1121 Prior Authorization of Analgesics Narcotic Short Acting—Pharmacy Services 3/29/13 01-13-16
08-13-16
14-13-15
30-13-15
33-13-17
02-13-15
09-13-17
24-13-16
31-13-18
03-13-15
11-13-15
27-13-16
32-13-15Ch. 1121 Prior Authorization of Bladder Relaxant Preparations—Pharmacy Services 3/29/13 01-13-14
09-13-15
27-13-14
33-13-15
02-13-13
11-13-13
30-13-13
03-13-13
14-13-13
31-13-16
08-13-14
24-13-14
32-13-13Ch. 1121 Prior Authorization of Bronchodilators Beta Agonists Short Acting Agents—Pharmacy Services 3/29/13 01-13-17
08-13-17
14-13-16
30-13-16
33-13-18
02-13-16
09-13-18
24-13-17
31-13-19
03-13-16
11-13-16
27-13-17
32-13-16Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 3/29/13 01-13-13
08-13-13
14-13-12
30-13-12
33-13-14
02-13-12
09-13-14
24-13-13
31-13-15
03-13-12
11-13-12
27-13-13
32-13-12Ch. 1121 Prior Authorization of Chronic Obstructive Pulmonary Disease (COPD) Agents—Pharmacy Services 3/29/13 01-13-15
09-13-16
27-13-15
33-13-16
02-13-14
11-13-14
30-13-14
03-13-14
14-13-14
31-13-17
08-13-15
24-13-15
32-13-14Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions for Procedure Code K0606 04/01/13 24-13-10
25-13-01Ch. 1101
Ch. 1150Medical Assistance Program Fee Schedule Revisions 04/15/13 99-13-03 Ch. 1121 Medical Assistance Pharmacy Benefit Package Update 04/22/13 99-13-20
14-13-17
18-13-01
24-13-18
17-13-18
31-13-21
33-13-20Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 5/3/13 01-13-19
09-13-21
27-13-19
33-13-21
02-13-17
11-13-17
30-13-17
03-13-17
14-13-18
31-13-22
08-13-19
24-13-19
32-13-17Ch. 1101 Revised Physician Attestation Form for Primary Care Services 5/3/13 31-13-32 Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents Oral and Inhaled—
Pharmacy Services5/3/13 01-13-23
09-13-25
27-13-23
33-13-25
02-13-21
11-13-21
30-13-21
03-13-21
14-13-22
31-13-26
08-13-23
24-13-23
32-13-21Ch. 1121 Prior Authorization of Lyrica (pregabalin) Neuropathic Pain Agents and Oral Anticonvulsants—Pharmacy Services 5/3/13 01-13-25
09-13-27
27-13-25
33-13-27
02-13-23
11-13-23
30-13-23
03-13-23
14-13-24
31-13-28
08-13-25
24-13-25
32-13-23Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services5/3/13 01-13-20
09-13-22
27-13-20
33-13-22
02-13-18
11-13-18
30-13-18
03-13-18
14-13-19
31-13-23
08-13-20
24-13-20
32-13-18Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and Type B)—Pharmacy Services 5/3/13 01-13-21
09-13-23
27-13-21
33-13-23
02-13-19
11-13-19
30-13-19
03-13-19
14-13-20
31-13-24
08-13-21
24-13-21
32-13-19Ch. 1121 Prior Authorization of Benzodiazepines; Analgesics Narcotic Long Acting; and Analgesics Narcotic Short Acting—Pharmacy Services 5/3/13 01-13-26
09-13-28
27-13-26
33-13-28
02-13-24
11-13-24
30-13-24
03-13-24
14-13-25
31-13-29
08-13-26
24-13-26
32-13-24Ch. 1121 Medicare Part D Coverage of Barbiturates and Benzodiazepines—Pharmacy Services 5/3/13 01-13-28
08-13-28
14-13-27
30-13-26
33-13-30
02-13-26
09-13-30
24-13-28
31-13-31
03-13-26
11-13-26
27-13-28
32-13-26Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 5/3/13 01-13-27
09-13-29
27-13-27
33-13-29
02-13-25
11-13-25
30-13-25
03-13-25
14-13-26
31-13-30
08-13-27
24-13-27
32-13-25Ch. 1121 340B Drug Pricing Program Provider Requirements and Billing Instructions—Pharmacy Services 5/16/13 99-13-08 Ch. 1101 Application of InvestiClaimTM Analytics to Select Claims 5/17/13 99-13-09 Ch. 1150 Implementation of the Medical Assistance Program's Physician Fee Increases for Select Primary Care Services 5/23/13 31-13-34 Ch. 1150 Addition to the Medical Assistance Program Fee Schedule for Administration of Flu Vaccine Derived from Cell Cultures: Flucelvax 5/25/13 01-13-18
08-13-18
09-13-19
31-13-20
33-13-19Ch. 1121 Prior Authorization of Androgenic Agents—Pharmacy Services 5/31/13 01-13-22
02-13-20
03-13-20
08-13-22
09-13-24
11-13-20
14-13-21
24-13-22
27-13-22
30-13-20
31-13-25
32-13-20
33-13-24Ch. 1121 Prior Authorization of H.P. Acthar Gel—Pharmacy Services 5/31/13 01-13-24
02-13-22
03-13-22
08-13-24
09-13-26
11-13-22
14-13-23
24-13-24
27-13-24
30-13-22
31-13-27
32-13-22
33-13-26Ch. 1150 2013 HCPCS Updates and Other Procedure Code Changes 6/24/13 99-13-07 Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 7/2/13 01-13-38 02-13-34
03-13-34
08-13-36
09-13-38
11-13-34
14-13-35
24-13-36
27-13-36
30-13-34
31-13-42
32-13-34
33-13-38Ch. 1121 Prior Authorization of Antiparasitics Topical—Pharmacy Services 7/2/13 01-13-37
02-13-33
03-13-33
08-13-35
09-13-37
11-13-33
14-13-34
24-13-35
27-13-35
30-13-33
31-13-41
32-13-33
33-13-37Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—Pharmacy Services 7/2/13 01-13-39
02-13-35
03-13-35
08-13-37
09-13-39
11-13-35
14-13-36
24-13-37
27-13-37
30-13-35
31-13-43
32-13-35
33-13-39Ch. 1150 Hospital Payment Arrangements 1 and 2 for Emergency Room Services 7/2/13 01-13-29
31-13-33Ch. 1121 Prior Authorization of Vasodilators Coronary—
Pharmacy Services7/2/13 01-13-36
02-13-32
03-13-32
08-13-34
09-13-36
11-13-32
14-13-33
24-13-34
27-13-34
30-13-32
31-13-40
32-13-32
33-13-36Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 7/2/13 01-13-34
02-13-30
03-13-30
08-13-32
09-13-34
11-13-30
14-13-31
24-13-32
27-13-32
30-13-30
31-13-38
32-13-30
33-13-34Ch. 1121 Prior Authorization of H. Pylori Treatments—
Pharmacy Services7/2/13 01-13-32
02-13-28
03-13-28
08-13-30
09-13-32
11-13-28
14-13-29
24-13-30
27-13-30
30-13-28
31-13-36
32-13-28
33-13-32Ch. 1121 Preferred Drug List (PDL) Update July 24, 2013—
Pharmacy Services7/7/13 01-13-31
09-13-31
27-13-29
33-13-31
02-13-27
11-13-27
30-13-27
03-13-27
14-13-28
31-13-35
08-13-29
24-13-29
32-13-27Ch. 1121 Prior Authorization of Colony Stimulating Factors—
Pharmacy Services7/13/13 01-13-33
09-13-33
27-13-31
33-13-33
02-13-29
11-13-29
30-13-29
03-13-29
14-13-30
31-13-37
08-13-31
24-13-31
32-13-29Ch. 1121 Prior Authorization of Irritable Bowel Syndrome Agents—Pharmacy Services 7/13/13 01-13-35
09-13-35
27-13-33
33-13-35
02-13-31
11-13-31
30-13-31
03-13-31
14-13-32
31-13-39
08-13-33
24-13-33
32-13-31Ch. 1121 Prior Authorization of Acne Agents Oral—
Doxycycline—Pharmacy Services7/22/13 01-13-40
08-13-38
14-13-37
30-13-36
33-13-40
02-13-36
09-13-40
24-13-38
31-13-44
03-13-36
11-13-36
27-13-38
32-13-36
Ch. 1127
Ch. 1150Changes to the Payment Structure for Birth Center Services 8/29/13 09-13-13
31-13-14
33-13-13
47-13-01Ch. 1101 Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2014 for Eligible Hospitals (EH) 9/20/13 01-13-41 Ch. 1101 Implementation of ADA Claim Form—Version 2012 and Elimination of ADA Claim Form—Version 2006 9/20/13 17-13-01
19-13-01
20-13-01
27-13-39
31-13-45Ch. 1101
Ch. 1149
Ch. 1129Correction to the Procedures for Reporting of Other Provider Preventable Conditions (OPPCs) for Federally Qualified Health Centers Rural Health Clinics and Dentists 10/2/13 08-13-39
27-13-41Ch. 1101 Application of InvestiClaimTM Analytics to Select Claims—Update 10/4/13 99-13-12 Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 11/4/13 01-13-45
09-13-45
27-13-45
33-13-44
02-13-40
11-13-40
30-13-40
03-13-40
14-13-41
31-13-50
08-13-43
24-13-42
32-13-40Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Services11/4/13 01-13-44
09-13-44
27-13-44
33-13-43
02-13-39
11-13-39
30-13-39
03-13-39
14-13-40
31-13-49
08-13-42
24-13-41
32-13-39Ch. 1121 Prior Authorization of Benign Prostatic Hyperplasia (BPH) Treatment—Pharmacy Services 11/4/13 01-13-46
09-13-46
27-13-46
33-13-45
02-13-41
11-13-41
30-13-41
03-13-41
14-13-42
31-13-51
08-13-44
24-13-43
32-13-41Ch. 1121 Prior Authorization of HIV/AIDS Medications—
Pharmacy Services11/4/13 01-13-47
09-13-47
27-13-47
33-13-46
02-13-42
11-13-42
30-13-42
03-13-42
14-13-43
31-13-52
08-13-45
24-13-44
32-13-42Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 11/4/13 01-13-42
09-13-42
27-13-42
33-13-41
02-13-37
11-13-37
30-13-37
03-13-37
14-13-38
31-13-47
08-13-40
24-13-39
32-13-37Ch. 1121 Prior Authorization of Leukotriene Modifiers—
Pharmacy Services11/4/13 01-13-48 09-13-48
27-13-48
33-13-47
02-13-43
11-13-43
30-13-43
03-13-43
14-13-44
31-13-53
08-13-46
24-13-45
32-13-43Ch. 1121 Prior Authorization of Angiotensin Modulator Combinations—Pharmacy Services 11/4/13 01-13-43
09-13-43
27-13-43
33-13-42
02-13-38
11-13-38
30-13-38
03-13-38
14-13-39
31-13-48
08-13-41
24-13-40
32-13-38Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 11/22/13 01-13-52
09-13-50
27-13-49
33-13-49
02-13-44
11-13-44
30-13-44
03-13-44
14-13-45
31-13-57
08-13-49
24-13-46
32-13-44Ch. 1121 Prior Authorization of Analgesics
Narcotic Long Acting
Analgesics
Narcotic Short Acting and Cough and Cold Medications—Pharmacy Services11/22/13 01-13-55
09-13-53
27-13-52
33-13-52
02-13-47
11-13-47
30-13-47
03-13-47
14-13-48
31-13-60
08-13-52
24-13-49
32-13-47Ch. 1121 Prior Authorization of Vecamyl (mecamylamine)—
Pharmacy Services11/22/13 01-13-54
09-13-52
27-13-51
33-13-51
02-13-46
11-13-46
30-13-46
03-13-46
14-13-47
31-13-59
08-13-51
24-13-48
32-13-46Ch. 1121 Prior Authorization of Lipotropics Other—Pharmacy Services 11/22/13 01-13-53
09-13-51
27-13-50
33-13-50
02-13-45
11-13-45
30-13-45
03-13-45
14-13-46
31-13-58
08-13-50
24-13-47
32-13-45Ch. 1101 CAQH CORE Federal Mandate: Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) 11/22/13 99-13-14 Ch. 1101 Presumptive Eligibility as Determined by Hospitals 12/6/13 01-13-56 Ch. 1121 Preferred Drug List (PDL) Update January 22, 2014—
Pharmacy Services12/18/13 01-13-57
02-13-48
03-13-48
08-13-53
09-13-54
11-13-48
14-13-49
24-13-50
27-13-53
30-13-48
31-13-61
32-13-48
33-13-53Ch. 1150 Medical Assistance Program Fee Schedule Revisions 12/27/13 99-13-13 2014 Ch. 1150 Additions to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent Flu Vaccine 08-14-02 1/7/14 01-14-03
09-14-01
31-14-02
33-14-01Ch. 1101 Changes to MA 112 Newborn Eligibility Form 1/10/14 01-14-02
47-14-01Ch. 1101 Implementation of the CMS-1500 Health Insurance Claim Form (version 02-12) 1/10/14
99-14-03 Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 1/20/14 01-14-05
09-14-03
27-14-02
33-14-03
02-14-02
11-14-02
30-14-02
03-14-02
14-14-02
31-14-04
08-14-04
24-14-02
32-14-02Ch. 1121 Prior Authorization of Antipsoriatics Oral—Pharmacy Services 1/20/14 01-14-04
08-14-03
14-14-01
30-14-01
33-14-02
02-14-01
09-14-02
24-14-01
31-14-03
03-14-01
11-14-01
27-14-01
32-14-01Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 2/3/14 01-14-06
02-14-03
03-14-03
08-14-05
09-14-04
11-14-03
14-14-03
24-14-03
27-14-03
30-14-03
31-14-05
32-14-03
33-14-04Ch. 1121 Prior Authorization of Histamine II Receptor Blockers—Pharmacy Services 2/3/14 01-14-08
09-14-06
27-14-05
33-14-06
02-14-05
11-14-05
30-14-05
03-14-05
14-14-05
31-14-07
08-14-07
24-14-05
32-14-05Ch. 1121 Prior Authorization of Oncology Agents Oral—
Pharmacy Services2/3/14 01-14-11
09-14-09
27-14-08
33-14-09
02-14-08
11-14-08
30-14-08
03-14-08
14-14-08
31-14-10
08-14-10
24-14-08
32-14-08Ch. 1121 Prior Authorization of Epinephrine Self-Injected—
Pharmacy Services2/3/14 01-14-07
09-14-05
27-14-04
33-14-05
02-14-04
11-14-04
30-14-04
03-14-04
14-14-04
31-14-06
08-14-06
24-14-04
32-14-04Ch. 1121 Prior Authorization of Immunomodulators Topical—
Pharmacy Services2/3/14 01-14-09
09-14-07
27-14-06
33-14-07
02-14-06
11-14-06
30-14-06
03-14-06
14-14-06
31-14-08
08-14-08
24-14-06
32-14-06Ch. 1121 Prior Authorization of Iron Oral—Pharmacy Services 2/3/14 01-14-10
09-14-08
27-14-07
33-14-08
02-14-07
11-14-07
30-14-07
03-14-07
14-14-07
31-14-09
08-14-09
24-14-07
32-14-07Ch. 1121 Prior Authorization of Progestational Agents—Pharmacy Services 2/3/14 01-14-12
09-14-10
27-14-09
33-14-10
02-14-09
11-14-09
30-14-09
03-14-09
14-14-09
31-14-11
08-14-11
24-14-09
32-14-09Ch. 1150 Sample Review of Physicians Receiving Increased Fees for Select Primary Care Services 2/18/14 31-14-12 Ch. 1121 Specialty Pharmacy Drug Program—Updated List of Covered Drugs—Pharmacy Services 2/18/14 99-14-05 Ch. 1101 Provider Credentialing by the Pennsylvania Medical Assistance Program 2/27/14 99-14-02 Ch. 1101 Re-enrollment/Revalidation of Medical Assistance (MA) Providers 3/7/14 99-14-06 Ch. 1149 2014 Recommended Childhood and Adolescent Immunization Schedules 4/1/14 99-14-07 Ch. 1121 Prior Authorization of Prescriptions That Exceed Established Quantity Limits/Daily Dose Limits—
Pharmacy Services4/25/14 01-14-18
09-14-13
27-14-11
33-14-12
02-14-11
11-14-11
30-14-11
03-14-14
14-14-11
31-14-16
08-14-14
24-14-11
32-14-11Ch. 1121 Prior Authorization of Kalydeco. (ivacaftor)—Pharmacy Services 4/25/14 01-14-17
02-14-10
03-14-13
08-14-13
09-14-12
11-14-10
14-14-10
24-14-10
27-14-10
30-14-10
31-14-15
32-14-10
33-14-11Ch. 1243 Addition to the Medical Assistance Program Fee Schedule—Oncotype DX 5/6/14 01-14-16
08-14-12
09-14-11
28-14-01
31-14-14
Ch. 1121 Prior Authorization of Analgesics Narcotic Long Acting—Pharmacy Services 05/30/14 01-14-24
09-14-19
27-14-17
33-14-18
02-14-16
11-14-16
30-14-16
03-14-19
14-14-16
31-14-22
08-14-20
24-14-16
32-14-16Ch. 1121 Prior Authorization of Immune Globulins—Pharmacy Services 05/30/14 01-14-25
09-14-20
27-14-18
33-14-19
02-14-17
11-14-17
30-14-17
03-14-20
14-14-17
31-14-23
08-14-21
24-14-17
32-14-17Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 05/30/14 01-14-22
09-14-17
27-14-15
33-14-16
02-14-14
11-14-14
30-14-14
03-14-17
14-14-14
31-14-20
08-14-18
24-14-14
32-14-14Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Services 05/30/14 01-14-21
09-14-16
27-14-14
33-14-15
02-14-13
11-14-13
30-14-13
03-14-16
14-14-13
31-14-19
08-14-17
24-14-13
32-14-13Ch. 1121 Prior Authorization of Botulinum Toxins (Type A and Type B)—Pharmacy Services 05/30/14 01-14-23
09-14-18
27-14-16
33-14-17
02-14-15
11-14-15
30-14-15
03-14-18
14-14-15
31-14-21
08-14-19
24-14-15
32-14-15Ch. 1121 Prior Authorization of Alzheimer's Agents—Pharmacy Services 05/30/14 01-14-20
09-14-15
27-14-13
33-14-14
02-14-12
11-14-12
30-14-12
03-14-15
14-14-12
31-14-18
08-14-16
24-14-12
32-14-12Ch. 1101 2014 HCPCS Updates and Other Procedure Code Changes 06/13/14 99-14-04 Ch. 1121 Preferred Drug List (PDL) Updated July 22, 2014—
Pharmacy Services07/07/14 01-14-26
09-14-21
27-14-19
33-14-20
02-14-18
11-14-18
30-14-18
03-14-21
14-14-18
31-14-24
08-14-22
24-14-18
32-14-18Ch. 1141
1150ACA Primary Care Services 2014 Fee Schedule 07/07/14 31-14-13 Ch. 1121 Prior Authorization of Hypoglycemic, Alpha—
Glucosidase Inhibitors—Pharmacy Services07/25/14 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
33-14-28
Ch. 1121 Prior Authorization of Hypoglycemics, Sulfonylureas—
Pharmacy Services07/25/14 01-14-35
02-14-27
03-14-30
08-14-31
09-14-30
11-14-27
14-14-27
24-14-27
27-14-28
30-14-27
31-14-33
32-14-27
33-14-29Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services07/25/14 01-14-36
02-14-28
03-14-31
08-14-32
09-14-31
11-14-28
14-14-28
24-14-28
27-14-29
30-14-28
31-14-34
32-14-28
33-14-30Ch. 1121 Prior Authorization of Antiparasitics, Topical—
Pharmacy Services07/25/14 01-14-31
09-14-26
27-14-24
33-14-25
02-14-23
11-14-23
30-14-23
03-14-26
14-14-23
31-14-29
08-14-27
24-14-23
32-14-23Ch. 1121 Prior Authorization of Antimigraine Agents, Other—
Pharmacy Services07/25/14
01-14-29
09-14-24
27-14-22
33-14-23
02-14-21
11-14-21
30-14-21
03-14-24
14-14-21
31-14-27
08-14-25
24-14-21
32-14-21Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 07/25/14 01-14-28
02-14-20
03-14-23
08-14-24
09-14-23
11-14-20
14-14-20
24-14-20
27-14-21
30-14-20
31-14-26
32-14-20
33-14-22Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 07/25/14 01-14-38
02-14-30
03-14-33
08-14-34
09-14-33
11-14-30
14-14-30
24-14-30
27-14-31
30-14-30
31-14-36
32-14-30
33-14-32Ch. 1121 Prior Authorization of Nitrofuran Derivatives—
Pharmacy Services07/25/14 01-14-37
02-14-29
03-14-32
08-14-33
09-14-32
11-14-29
14-14-29
24-14-29
27-14-30
30-14-29
31-14-35
32-14-29
33-14-31Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—Pharmacy Services 07/25/14 01-14-32
09-14-27
27-14-25
33-14-26
02-14-24
11-14-24
30-14-24
03-14-27
14-14-24
31-14-30
08-14-28
24-14-24
32-14-24
Ch. 1121 Prior Authorization of Thyroid Hormones—Pharmacy Services 07/25/14 01-14-39
02-14-31
03-14-34
08-14-35
09-14-34
11-14-31
14-14-31
24-14-31
27-14-32
30-14-31
31-14-37
32-14-31
33-14-33Ch. 1121 Prior Authorization of Acne Agents, Oral—Pharmacy Services 08/05/14 01-14-27
09-14-22
27-14-20
33-14-21
02-14-19
11-14-19
30-14-19
03-14-22
14-14-19
31-14-25
08-14-23
24-14-19
32-14-19Ch. 1121 Prior Authorization of Ulcerative Colitis Agents—
Pharmacy Services08/05/14 01-14-40
09-14-35
27-14-33
33-14-34
02-14-32
11-14-32
30-14-32
03-14-35
14-14-32
31-14-38
08-14-36
24-14-32
32-14-32Ch. 1121 Prior Authorization of Antimigraine Agents, Triptans—
Pharmacy Services08/05/14 01-14-30
09-14-25
27-14-23
33-14-24
02-14-22
11-14-22
30-14-22
03-14-25
14-14-22
31-14-28
08-14-26
24-14-22
32-14-22Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 08/11/14 01-14-41
09-14-36
27-14-34
33-14-35
02-14-33
11-14-33
30-14-33
03-14-36
14-14-33
31-14-39
08-14-37
24-14-33
32-14-33Ch. 1101 Implementation of National Correct Coding Initiative Related Modifiers 09/12/14 99-14-08 Ch. 1149
1150New Procedure Code for Dental Services 09/27/14 27-14-12 Ch. 1101
1150Presumptive Eligibility for Pregnant Women 10-24-14 01-14-19
08-14-15
09-14-14
31-14-17
33-14-13
47-14-02Ch. 1101 Implementation of Healthy Pennsylvania 11/04/14 99-14-09 Ch. 1101
1141
1150
1221Advanced Radiologic Imaging Services 11/21/14 01-14-42 Ch. 1123 Revisions to Prior Authorization Requirements For Apnea Monitors 12/09/14 24-14-34
25-14-01Ch. 1101 Healthy PA Benefit Plans 12/12/14 99-14-10 Ch. 1141
1150Medical Assistance Fees for Primary Care Services 12/20/14 31-14-40 Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/29/14 01-14-53
02-14-43
03-14-46
08-14-47
09-14-46
11-14-43
14-14-43
24-14-44
27-14-44
30-14-43
31-14-50
32-14-43
33-14-45Ch. 1121 Prior Authorization of Anti-Allergens, Oral—Pharmacy Services 12/29/14 01-14-47
09-14-40
27-14-38
33-14-39
02-14-37
11-14-37
30-14-37
03-14-40
14-14-37
31-14-44
08-14-41
24-14-38
32-14-37Ch. 1121 Prior Authorization of Rilutek (riluzole)—Pharmacy Services 12/29/14 01-14-51
02-14-41
03-14-44
08-14-45
09-14-44
11-14-41
14-14-41
24-14-42
27-14-42
30-14-41
31-14-48
32-14-41
33-14-43Ch. 1121 Prior Authorization of Compounded Prescriptions—
Pharmacy Services12/29/14 01-14-44
02-14-34
03-14-37
08-14-38
09-14-37
11-14-34
14-14-34
24-14-35
27-14-35
30-14-34
31-14-41
32-14-34
33-14-36Ch. 1121 Prior Authorization of Cytokine And CAM Antagonists—Pharmacy Services 12/29/14 01-14-52
02-14-42
03-14-45
08-14-46
09-14-45
11-14-42
14-14-42
24-14-43
27-14-43
30-14-42
31-14-49
32-14-42
33-14-44Ch. 1121 Prior Authorization of Soliris (eculizumab)—Pharmacy Services 12/29/14 01-14-48
09-14-41
27-14-39
33-14-40
02-14-38
11-14-38
30-14-38
03-14-41
14-14-38
31-14-45
08-14-42
24-14-39
32-14-38Ch. 1121 Prior Authorization of Mozobil (Plerixafor)—Pharmacy Services 12/29/14 01-14-49
09-14-42
27-14-40
33-14-41
02-14-39
11-14-39
30-14-39
03-14-42
14-14-39
31-14-46
08-14-43
24-14-40
32-14-39Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—
Pharmacy Services12/29/14 01-14-50
02-14-40
03-14-43
08-14-44
09-14-43
11-14-40
14-14-40
24-14-41
27-14-41
30-14-40
31-14-47
32-14-40
33-14-42Ch. 1121 Prior Authorization of Xolair—Pharmacy Services 12/29/14 01-14-45
02-14-35
03-14-38
08-14-39
09-14-38
11-14-35
14-14-35
24-14-36
27-14-36
30-14-35
31-14-42
32-14-35
33-14-37Ch. 1121 Prior Authorization of Ranexa (ranolazine)—Pharmacy Services 12/29/14 01-14-46
02-14-36
03-14-39
08-14-40
09-14-39
11-14-36
14-14-36
24-14-37
27-14-37
30-14-36
31-14-43
32-14-36
33-14-38Ch. 1150
1245Non-Payment of Unloaded Ground or Air Ambulance Mileage 12/30/14 26-14-01 2015 Ch. 1101 Healthy PA Interim Benefit Plan 01/14/15 99-15-02 Ch. 1130 Hospice Services 01/19/15 06-15-01
09-14-47
31-14-51Ch. 1121 Prior Authorization of Sedative Hypnotics—Pharmacy Services 02/04/15 01-15-04
02-15-03
03-15-03
08-15-04
09-15-04
11-15-03
14-15-03
24-15-03
27-15-03
30-15-03
31-15-04
32-15-03
33-15-04Ch. 1121 Prior Authorization of Thalidomide And Derivatives—
Pharmacy Services02/04/15 01-15-06
02-15-05
03-15-05
08-15-06
09-15-06
11-15-05
14-15-05
24-15-05
27-15-05
30-15-05
31-15-06
32-15-05
33-15-06Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Services 02/04/15 01-15-03
02-15-02
03-15-02
08-15-03
09-15-03
11-15-02
14-15-02
24-15-02
27-15-02
30-15-02
31-15-03
32-15-02
33-15-03Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 02/04/15 01-15-05
02-15-04
03-15-04
08-15-05
09-15-05
11-15-04
04-15-04
24-15-04
27-15-04
30-15-04
31-15-05
32-15-04
33-15-05Ch. 1121 Addition to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent—
Influenza Vaccine02/18/15 01-15-01
08-15-01
09-15-01
31-15-01
33-15-01Ch. 1121 Preferred Drug List (PDL) Update January 21, 2015—
Pharmacy Services02/18/15 01-15-02
09-15-02
27-15-01
33-15-02
02-15-01
11-15-01
30-15-01
03-15-01
14-15-01
31-15-02
08-15-02
24-15-01
32-15-01Ch. 1163 Revised Presumptive Eligibility as Determined by Hospitals 02/24/15 01-15-08 Ch. 1101 Medical Assistance Program Fee Schedule Revisions 03/02/15 99-15-01* Ch. 1101 Medical Assistance Program Fee 03/17/15 99-15-03 Ch. 1101
1150
1225Payment Increase for the Title XIX Medical Assistance Program Family Planning Clinics that Dispense Oral Contraceptives 03/23/15 08-15-08 Ch. 1241 2015 Recommended Childhood and Adolescent Immunization Schedules 03/23/15 99-15-04 Ch. 1150
1245Non-Payment of Unloaded Ground or Air Ambulance Mileage 03/23/15 26-15-01 Ch. 1121 Implementation of HealthChoices Medicaid Expansion 04/28/15 99-15-05 Ch. 1121 Prior Authorization of Idiopathic Fibrosis Agent—
Pharmacy Service05/11/15 01-15-14
02-15-12
03-15-12
08-15-14
09-15-13
11-15-12
14-15-12
24-15-12
27-15-12
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Hypoglycemics, Insulin—
Pharmacy Services05/11/15 01-15-10
02-15-08
03-15-08
08-15-10
09-15-09
11-15-08
14-15-08
24-15-08
27-15-08
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Intra-Articular Hyaluronic Acid Agents—Pharmacy Service 05/11/15 01-15-12
02-15-10
03-15-10
08-15-12
09-15-11
11-15-10
14-15-10
24-15-10
27-15-10
30-15-10
31-15-11
32-15-10
33-15-11Ch. 1121 Prior Authorization of Santyl Ointment (collagenase)—
Pharmacy Service05/11/15 01-15-13
02-15-11
03-15-11
08-15-13
09-15-12
11-15-11
14-15-11
24-15-11
27-15-11
30-15-11
31-15-12
32-15-11
33-15-12Ch. 1121 Prior Authorization of Multiple Sclerosis Agents—
Pharmacy Services05/11/15 01-15-09
02-15-07
03-15-07
08-15-09
09-15-08
11-15-07
14-15-07
24-15-07
27-15-07
30-15-07
31-15-08
32-15-07
33-15-08Ch. 1121 Prior Authorization of Antifungals, Topical—
Pharmacy Services06/22/15 01-15-17
02-15-14
03-15-14
08-15-17
09-15-17
11-15-14
14-15-14
24-15-15
27-15-14
30-15-14
31-15-17
32-15-14
33-15-16Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 06/22/15 01-15-16
02-15-13
03-15-13
08-15-16
09-15-16
11-15-13
14-15-13
24-15-14
27-15-13
30-15-13
31-15-16
32-15-13
33-15-15Ch. 1121 Prior Authorization of GI Motility, Chronic Agents (Formerly Irritable Bowel Syndrome Agents)—
Pharmacy Services06/25/15 01-15-18
02-15-15
03-15-15
08-15-18
09-15-18
11-15-15
14-15-15
24-15-16
27-15-15
30-15-15
31-15-18
32-15-15
33-15-17Ch. 1121 Preferred Drug List (PDL) Update July 20, 2015—
Pharmacy Services06/25/15 01-15-23
02-15-20
03-15-20
08-15-23
09-15-23
11-15-20
14-15-20
24-15-21
27-15-20
30-15-20
31-15-23
32-15-20
33-15-22Ch. 1121 Prior Authorization of Platelet Aggregation Inhibitors—Pharmacy Services 06/25/15 01-15-20
02-15-17
03-15-17
08-15-20
09-15-20
11-15-17
14-15-17
24-15-18
27-15-17
30-15-17
31-15-20
32-15-17
33-15-19Ch. 1121 Prior Authorization of Contraceptives, Other—
Pharmacy Services06/25/15 01-15-19
02-15-16
03-15-16
08-15-19
09-15-19
11-15-16
14-15-16
24-15-17
27-15-16
30-15-16
31-15-19
32-15-16
33-15-18Ch. 1121 Prior Authorization of Hypoglycemics, SGLT2 Inhibitors—Pharmacy Services 06/25/15 01-15-22
02-15-19
03-15-19
08-15-22
09-15-22
11-15-19
14-15-19
24-15-20
27-15-19
30-15-19
31-15-22
32-15-19
33-15-21Ch. 1127
1141
1221
1225Family Planning Services 6/29/15 01-15-15
08-15-15
09-15-15
24-15-13
25-15-01
28-15-01
31-15-15
33-15-14Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Service 06/30/15 01-15-21
02-15-18
03-15-18
08-15-21
09-15-21
11-15-18
14-15-18
24-15-19
27-15-18
30-15-18
31-15-21
32-15-18
33-15-20Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy Service 07/13/15 01-15-11
02-15-09
03-15-09
08-15-11
09-15-10
11-15-09
14-15-09
24-15-09
27-15-09
30-15-09
31-15-10
32-15-09
33-15-10Ch. 1121 Preferred Drug List (PDL) Update July 20, 2015 Corrections—Pharmacy Services 08/07/15 01-15-26
02-15-23
03-15-23
08-15-26
09-15-26
11-15-23
14-15-23
24-15-24
27-15-23
30-15-23
31-15-26
32-15-23
33-15-25Ch. 1241 Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 08/10/15 99-15-07 Ch. 1121 Specialty Pharmacy Drug Program—Pharmacy Services 08/20/15 99-15-08 Ch. 1101
1150Medical Assistance (MA) Program's Implementation of ICD-10 Diagnosis and Procedure Code Sets 08/28/15 99-15-09 Ch. 1101
1150Addition to the Medical Assistance Program Fee Schedule for Administration of HPV 9 Vaccine 08/31/15 01-15-29
08-15-29
09-15-29
31-15-29
33-15-28Ch. 1101
1150Prior Authorization Requirements and Fee Schedule Updates for Hyperbaric Oxygen Therapy 08/31/15 01-15-30
14-15-25
31-15-30Ch. 1101
11502015 HCPCS Updates and Other Procedure Codes 08/31/15 99-15-06 Ch. 1101
1150Procedure Code Changes for Application of Topical Fluoride Varnish by Physicians and CRNPs 09/01/15 09-15-14
31-15-14Ch. 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 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Service 09/04/15 01-15-24
09-15-24
27-15-21
02-15-21
11-15-21
30-15-21
03-15-21
14-15-21
31-15-24
08-15-24
24-15-22
32-15-21
33-15-23Ch. 1121 Prior Authorization of Opiate Dependence Treatments, Oral Buprenorphine Agents—Pharmacy Service 09/04/15 01-15-25
09-15-25
27-15-22
02-15-22
11-15-22
30-15-22
03-15-22
14-15-22
31-15-25
08-15-25
24-15-23
32-15-22
33-15-24Ch. 1241 Implementation of ICD-10 Diagnosis Sets for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screens 09/14/15 99-15-11 Ch. 1101
1150New Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Application for Benefits and Updated ICD-10 Codes 09/21/15 99-15-10 Ch. 1121 Trumenba and Bexsero Meningococcal B Vaccines 10/26/15 01-15-31
08-15-30
09-15-30
31-15-31
33-15-29Ch. 1121 Prior Authorization of Kalydeco, Nuedexta and Xyrem—Pharmacy Service 11/10/15 01-15-37
02-15-29
03-15-29
08-15-35
09-15-35
11-15-28
14-15-30
24-15-30
27-15-29
30-15-28
31-15-36
32-15-29
33-15-34Ch. 1121 Prior Authorization of Lipotropics, Other 11/13/15 01-15-33
02-15-25
03-15-25
08-15-31
09-15-31
11-15-24
14-15-26
24-15-26
27-15-25
30-15-24
31-15-32
32-15-25
33-15-30
Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—
Pharmacy Service11/13/15 01-15-35
02-15-27
03-15-27
08-15-33
09-15-33
11-15-26
14-15-28
24-15-28
27-15-27
30-15-26
31-15-34
32-15-27
33-15-32Ch. 1121 Prior Authorization of Antibiotics, GI—Pharmacy Service 11/13/15 01-15-36
02-15-28
03-15-28
08-15-34
09-15-34
11-15-27
14-15-29
24-15-29
27-15-28
30-15-27
31-15-35
32-15-28
33-15-33Ch. 1121 Prior Authorization of Angiotensin Modulators—
Pharmacy Service11/18/15 01-15-34
02-15-26
03-15-26
08-15-32
09-15-32
11-15-25
14-15-27
24-15-27
27-15-26
30-15-25
31-15-33
32-15-26
33-15-31Ch. 1163 Revised Procedures for Presumptive Eligibility as Determined by Hospitals 11/30/15 01-15-32 Ch. 1121 Prior Authorization of Corlanor (ivabradine)—
Pharmacy Service11/30/15 01-15-39
09-15-37
27-15-31
02-15-31
11-15-30
30-15-30
03-15-31
14-15-32
31-15-38
08-15-37
24-15-32
32-15-31
33-15-36Ch. 1121 Prior Authorization of Alpha-1 Proteinase Inhibitors—
Pharmacy Service11/30/15 01-15-38
09-15-36
27-15-30
02-15-30
11-15-29
30-15-29
03-15-30
14-15-31
31-15-37
08-15-36
24-15-31
32-15-30
33-15-35Ch. 1127
1141
1221
1225Implementation of ICD-10 Diagnosis Codes for the Family Planning Services Program 11/30/15 01-15-27
08-15-27
09-15-27
24-15-25
25-15-02
28-15-02
31-15-27
33-15-26Ch. 1121 Prior Authorization of Orkambi (lumacaftor/ivacaftor)—Pharmacy Service 11/30/15 01-15-40
09-15-38
27-15-32
02-15-32
11-15-31
30-15-31
03-15-32
14-15-33
31-15-39
08-15-38
24-15-33
32-15-32
33-15-37Ch. 1101
1150The Addition of Three-Dimensional (3D) Mammography Procedure Codes to the Medical Assistance Program Fee Schedule 12/09/15 01-15-41
08-15-39
09-15-39
31-15-40Ch. 1130
1249Hospice Two-Tiered Routine Home Care and Service Intensity Add-On Payments 12/31/15 06-15-02
09-15-40
31-15-41Ch. 1121 Preferred Drug List (PDL) Update January 20, 2016— Pharmacy Services 01/08/16 01-16-01
09-16-01
27-16-01
02-16-01
11-16-01
30-16-01
03-16-01
14-16-01
31-16-01
08-16-01
24-16-01
32-16-01
33-16-01Ch. 1121 Prior Authorization of Bile Salts—Pharmacy Service 01/06/16 01-16-02
09-16-02
27-16-02
02-16-02
11-16-02
30-16-02
03-16-02
14-16-02
31-16-02
08-16-02
24-26-02
32-16-02
33-16-02Ch. 1121 Prior Authorization of Duloxetine Agents—Pharmacy Service 01/06/16
01-16-07
09-16-07
27-16-07
02-16-07
11-16-07
30-16-07
03-16-07
14-16-07
31-16-07
08-16-07
24-16-07
32-16-07
33-16-07Ch. 1121 Prior Authorization of Methotrexate—Pharmacy Service 01/06/16 01-16-06
09-16-06
27-16-06
02-16-06
11-16-06
30-16-06
03-16-06
14-16-06
31-16-06
08-16-06
24-16-06
32-16-06
33-16-06Ch. 1121 Prior Authorization of Macular Degeneration Agents—
Pharmacy Service01/06/16 01-16-04
09-16-04
27-16-04
02-16-04
11-16-04
30-16-04
03-16-04
14-16-04
31-16-04
08-16-04
24-16-04
32-16-04
33-16-04Ch. 1121 Prior Authorization of COPD Agents—Pharmacy Service 01/06/16 01-16-03
09-16-03
27-16-03
02-16-03
11-16-03
30-16-03
03-16-03
14-16-03
31-16-03
08-16-03
24-16-03
32-16-03
33-16-03Ch. 1121 Prior Authorization of Antipsychotics—Pharmacy Service 01/06/16 01-16-08
09-16-08
27-16-08
02-16-08
11-16-08
30-16-08
03-16-08
14-16-08
31-16-08
08-16-08
24-16-08
32-16-08
33-16-08Ch. 1121 Prior Authorization of Stimulants and Related Agents—Pharmacy Service 01/06/16 01-16-05
09-16-05
27-16-05
02-16-05
11-16-05
30-16-05
03-16-05
14-16-05
31-16-05
08-16-05
24-16-05
32-16-05
33-16-05Ch. 1149 Required Training for the Application of Topical Fluoride Varnish 02/26/16 09-16-10
31-16-10Ch. 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 Service03/14/16 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 Service 03-14-16 01-16-11
09-16-13
27-16-11
02-16-11
11-16-11
30-16-11
03-16-11
14-16-11
31-16-13
08-16-11
24-16-12
32-16-11
33-16-11Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Service 03/14/16 01-16-10
09-16-12
27-16-10
02-16-10
11-16-10
30-16-10
03-16-10
14-16-10
31-16-12
08-16-10
24-16-11
32-16-10
33-16-10
Ch. 1140 Updates to the Medical Assistance Program Fee Schedule For Healthy Beginnings Plus 03/18/16 01-16-12
05-16-02
08-16-12
31-16-14
33-16-12
47-16-01Ch. 1101 Enrollment of Ordering, Referring and Prescribing Providers 04/01/16 99-16-07 Ch. 1101 Revalidation of Medical Assistance (MA) Providers 04/15/16 99-16-06 Ch. 1241 2016 Recommended Childhood and Adolescent Immunization Schedules 04/15/16 99-16-05 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. 1101 ACA Enrollment Application Fee 06/01/16 01-16-14
02-16-12
03-16-12
04-16-01
05-16-03
06-16-01
07-16-01
08-16-13
11-16-12
12-16-01
24-16-13
25-16-02
26-16-01
28-16-01
29-16-01
30-16-12
47-16-02
56-16-01
59-16-01Ch. 1121 Prior Authorization of Nucala (mepolizumab)—
Pharmacy Service06-13-26 01-16-16
09-16-15
27-16-14
02-16-14
11-16-14
30-16-14
03-16-14
14-16-14
31-16-17
08-16-15
24-16-15
32-16-13
33-16-14Ch. 1121 Prior Authorization of Provenge (sipuleucel-T)—
Pharmacy Service06/13/16 01-16-17
09-16-16
27-16-15
02-16-15
11-16-115
30-16-15
03-16-15
14-16-15
31-16-18
08-16-16
24-16-16
32-16-14
33-16-15Ch. 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. 1249Face-to-Face Encounter Requirements for Prescribing of Home Health Services Including Durable Medical Equipment and Medical Supplies 06/27/2016 05-16-04
24-16-18
25-16-03
31-16-21Ch. 1101 2016 Healthcare Common Procedure Coding System (HCPCS) Updates and Other Procedure Code Changes 06/27/2016 99-16-08 Ch. 1150 Observation Services 06/27/2016 01-16-19
14-16-17
27-16-17
31-16-20Ch. 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 07/05/2016 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 Cephalosporins and Related Agents—Pharmacy Services 07/05/2016 01-16-28
09-16-26
27-16-26
02-16-25
11-16-25
30-16-25
03-16-25
14-16-26
31-16-30
08-16-26
24-16-28
32-16-24
33-16-25Ch. 1121 Preferred Drug List (PDL) Update July 18, 2016—
Pharmacy Services07/05/16 01-16-26
09-16-24
27-16-24
02-16-23
11-16-23
30-16-23
03-16-23
14-16-24
31-16-28
08-16-24
24-16-26
32-16-22
33-16-23Ch. 1121 Prior Authorization of Incretin Mimetic/Enhancer Hypoglycemics—Pharmacy Services 07/05/16 01-16-23
09-16-21
27-16-21
02-16-20
11-16-20
30-16-20
03-16-20
14-16-21
31-16-25
08-16-21
24-16-23
32-16-19
33-16-20Ch. 1121 Prior Authorization of Antifungals, Topical—Pharmacy Services 07/05/16 01-16-21
09-16-19
27-16-19
02-16-18
11-16-18
30-16-18
03-16-18
14-16-19
31-16-23
08-16-19
24-16-21
32-16-17
33-16-18
Ch. 1121 Prior Authorization of Tetracyclines—Pharmacy Services 07/05/16 01-16-25
09-16-23
27-16-23
02-16-22
11-16-22
30-16-22
03-16-22
14-16-23
31-16-27
08-16-23
24-16-25
32-16-21
33-16-22Ch. 1121 Prior Authorization of Opiate Overdose Agents—
Pharmacy Services07/07/16 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
33-16-21
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