[50 Pa.B. 4837]
[Saturday, September 19, 2020]
[Continued from previous Web Page]
Year Code Citation(s) Subject Date Issued Bulletin
Number2014 Ch. 1150 Additions to the Medical Assistance Program Fee Schedule for Administration of Quadrivalent Flu Vaccine 08-14-02 01/07/14 01-14-03
09-14-01
31-14-02
33-14-01Ch. 1101 Changes to MA 112 Newborn Eligibility Form 01/10/14 01-14-02
47-14-01Ch. 1101 Implementation of the CMS-1500 Health Insurance Claim Form (version 02-12) 01/10/14 99-14-03 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 Services 02/03/14 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 DX05/06/14 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 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 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 Services 07/07/14 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 Services 07/25/14 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 Services 07/25/14 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 Services07/25/14 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 Services07/25/14 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 Services 08/05/14 01-14-30
09-14-25
27-14-23
33-14-24
02-14-22
11-14-22
30-14-22
03-14-25
14-14-22
31-14-28
08-14-26
24-14-22
32-14-22Ch. 1121 Prior Authorization of Tysabri—Pharmacy Services 08/11/14 01-14-41
09-14-36
27-14-34
33-14-35
02-14-33
11-14-33
30-14-33
03-14-36
14-14-33
31-14-39
08-14-37
24-14-33
32-14-33Ch. 1101 Implementation of National Correct Coding Initiative Related Modifiers 09/12/14 99-14-08 Ch. 1149
1150New Procedure Code for Dental Services 09/27/14 27-14-12 Ch. 1101
1150Presumptive Eligibility for Pregnant Women 10/24/14 01-14-19
08-14-15
09-14-14
31-14-17
33-14-13
47-14-02Ch. 1101 Implementation of Healthy Pennsylvania 11/04/14 99-14-09 Ch. 1101
1141
1150
1221Advanced Radiologic Imaging Services 11/21/14 01-14-42 Ch. 1123 Revisions to Prior Authorization Requirements for Apnea Monitors 12/09/14 24-14-34
25-14-01Ch. 1101 Healthy PA Benefit Plans 12/12/14 99-14-10 Ch. 1141
1150Medical Assistance Fees for Primary Care Services 12/20/14 31-14-40 Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Services 12/29/14 01-14-53
02-14-43
03-14-46
08-14-47
09-14-46
11-14-43
14-14-43
24-14-44
27-14-44
30-14-43
31-14-50
32-14-43
33-14-45Ch. 1121 Prior Authorization of Anti-Allergens, Oral—Pharmacy Services 12/29/14 01-14-47
09-14-40
27-14-38
33-14-39
02-14-37
11-14-37
30-14-37
03-14-40
14-14-37
31-14-44
08-14-41
24-14-38
32-14-37Ch. 1121 Prior Authorization of Rilutek (riluzole)—Pharmacy Services 12/29/14 01-14-51
02-14-41
03-14-44
08-14-45
09-14-44
11-14-41
14-14-41
24-14-42
27-14-42
30-14-41
31-14-48
32-14-41
33-14-43Ch. 1121 Prior Authorization of Compounded Prescriptions—Pharmacy Services 12/29/14 01-14-44
02-14-34
03-14-37
08-14-38
09-14-37
11-14-34
14-14-34
24-14-35
27-14-35
30-14-34
31-14-41
32-14-34
33-14-36Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 12/29/14 01-14-52
02-14-42
03-14-45
08-14-46
09-14-45
11-14-42
14-14-42
24-14-43
27-14-43
30-14-42
31-14-49
32-14-42
33-14-44Ch. 1121 Prior Authorization of Soliris (eculizumab)—Pharmacy Services 12/29/14 01-14-48
09-14-41
27-14-39
33-14-40
02-14-38
11-14-38
30-14-38
03-14-41
14-14-38
31-14-45
08-14-42
24-14-39
32-14-38Ch. 1121 Prior Authorization of Mozobil (Plerixafor)—Pharmacy Services 12/29/14 01-14-49
09-14-42
27-14-40
33-14-41
02-14-39
11-14-39
30-14-39
03-14-42
14-14-39
31-14-46
08-14-43
24-14-40
32-14-39Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—Pharmacy 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 Services 02/04/15 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 Services 02/18/15 01-15-02
09-15-02
27-15-01
33-15-02
02-15-01
11-15-01
30-15-01
03-15-01
14-15-01
31-15-02
08-15-02
24-15-01
32-15-01Ch. 1163 Revised Presumptive Eligibility as Determined by Hospitals 02/24/15 01-15-08 Ch. 1101 Medical Assistance Program Fee Schedule Revisions 03/02/15 99-15-01* Ch. 1101 Medical Assistance Program Fee 03/17/15 99-15-03 Ch. 1101
1150
1225Payment Increase for the Title XIX Medical Assistance Program Family Planning Clinics that Dispense Oral Contraceptives 03/23/15 08-15-08 Ch. 1241 2015 Recommended Childhood and Adolescent Immunization Schedules 03/23/15 99-15-04 Ch. 1150
1245Non-Payment of Unloaded Ground or Air Ambulance Mileage 03/23/15 26-15-01 Ch. 1121 Implementation of HealthChoices Medicaid Expansion 04/28/15 99-15-05 Ch. 1121 Prior Authorization of Idiopathic Fibrosis Agent—Pharmacy Service 05/11/15 01-15-14
02-15-12
03-15-12
08-15-14
09-15-13
11-15-12
14-15-12
24-15-12
27-15-12
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Hypoglycemics, Insulin—Pharmacy Services 05/11/15 01-15-10
02-15-08
03-15-08
08-15-10
09-15-09
11-15-08
14-15-08
24-15-08
27-15-08
30-15-12
31-15-13
32-15-12
33-15-13Ch. 1121 Prior Authorization of Intra-Articular Hyaluronic Acid Agents—
Pharmacy Service05/11/15 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 Service 05/11/15 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—PharmacyServices 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—PharmacyServices 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 Services 06/25/15 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 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 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 06/29/15 01-15-15
08-15-15
09-15-15
24-15-13
25-15-01
28-15-01
31-15-15
33-15-14Ch. 1121 Prior Authorization of Hepatitis C Agents—Pharmacy Service 06/30/15 01-15-21
02-15-18
03-15-18
08-15-21
09-15-21
11-15-18
14-15-18
24-15-19
27-15-18
30-15-18
31-15-21
32-15-18
33-15-20Ch. 1121 Prior Authorization of Opiate Dependence Treatments—Pharmacy 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 Services08/07/15 01-15-26
02-15-23
03-15-23
08-15-26
09-15-26
11-15-23
14-15-23
24-15-24
27-15-23
30-15-23
31-15-26
32-15-23
33-15-25Ch. 1241 Revisions to the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Periodicity Schedule 08/10/15 99-15-07
Ch. 1101 1150 Prior Authorization Requirements and Fee Schedule Updates for Hyperbaric Oxygen Therapy 08/31/15 01-15-30
14-15-25
31-15-30
Ch. 1101 1150 2015 HCPCS Updates and Other Procedure Codes 08/31/15 99-15-06 Ch. 1101 1150 Procedure Code Changes for Application of Topical Fluoride Varnish by Physicians and CRNPs 09/01/15 09-15-14
31-15-14
Ch. 1126 1129
1151
1181
1187
1189Provider Preventable Conditions 09/01/15 01-15-28
03-15-24
09-15-28
18-15-02
31-15-28
33-15-27
02-15-24
08-15-28
14-15-24
27-15-24
32-15-24
47-15-01Ch. 1121 Specialty Pharmacy Drug Program—Pharmacy Services 08/20/15 99-15-08 Ch. 1101 1150 Medical Assistance (MA) Program's Implementation of ICD-10 Diagnosis and Procedure Code Sets 08/28/15 99-15-09 Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Service 09/04/15 01-15-24
09-15-24
27-15-21
02-15-21
11-15-21
30-15-21
03-15-21
14-15-21
31-15-24
08-15-24
24-15-22
32-15-21
33-15-23Ch. 1121 Prior Authorization of Opiate Dependence Treatments, Oral Buprenorphine Agents—Pharmacy Service 09/04/15 01-15-25
09-15-25
27-15-22
02-15-22
11-15-22
30-15-22
03-15-22
14-15-22
31-15-25
08-15-25
24-15-23
32-15-22
33-15-24Ch. 1241 Implementation of ICD-10 Diagnosis Sets for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Screens 09/14/15 99-15-11 Ch. 1101 1150 New Breast and Cervical Cancer Prevention and Treatment (BCCPT) Program Application for Benefits and Updated ICD-10 Codes 09/21/15 99-15-10 Ch. 1121 Trumenba and Bexsero Meningococcal B Vaccines 10/26/15 01-15-31
08-15-30
09-15-30
31-15-31
33-15-29Ch. 1121 Prior Authorization of Kalydeco, Nuedexta and Xyrem—
Pharmacy Service11/10/15 01-15-37
02-15-29
03-15-29
08-15-35
09-15-35
11-15-28
14-15-30
24-15-30
27-15-29
30-15-28
31-15-36
32-15-29
33-15-34Ch. 1121 Prior Authorization of Lipotropics, Other—Pharmacy Services 11/13/15 01-15-33
02-15-25
03-15-25
08-15-31
09-15-31
11-15-24
14-15-26
24-15-26
27-15-25
30-15-24
31-15-32
32-15-25
33-15-30Ch. 1121 Prior Authorization of GI Motility, Chronic Agents—Pharmacy Service 11/13/15 01-15-35
-15-27
03-15-27
08-15-33
09-15-33
11-15-26
14-15-28
24-15-28
27-15-27
30-15-26
31-15-34
32-15-27
33-15-32Ch. 1121 Prior Authorization of Antibiotics, GI—Pharmacy Service 11/13/15 01-15-36
02-15-28
03-15-28
08-15-34
09-15-34
11-15-27
14-15-29
24-15-29
27-15-28
30-15-27
31-15-35
32-15-28
33-15-33Ch. 1121 Prior Authorization of Angiotensin Modulators—Pharmacy Service 11/18/15 01-15-34
02-15-26
03-15-26
08-15-32
09-15-32
11-15-25
14-15-27
24-15-27
27-15-26
30-15-25
31-15-33
-15-26
33-15-31Ch. 1163 Revised Procedures for Presumptive Eligibility as Determined by Hospitals 11/30/15 01-15-32 Ch. 1121 Prior Authorization of Corlanor (ivabradine)—Pharmacy Service 11/30/15 01-15-39
09-15-37
27-15-31
02-15-31
11-15-30
30-15-30
03-15-31
14-15-32
31-15-38
08-15-37
24-15-32
32-15-31
33-15-36Ch. 1121 Prior Authorization of Alpha-1 Proteinase Inhibitors—Pharmacy Service 11/30/15 01-15-38
09-15-36
27-15-30
02-15-30
11-15-29
30-15-29
03-15-30
14-15-31
31-15-37
08-15-36
24-15-31
32-15-30
33-15-35Ch. 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 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
31-15-40Ch. 1130 1249 Hospice Two-Tiered Routine Home Care and Service Intensity Add-On Payments 12/31/15 06-15-02
09-15-40
31-15-41Ch. 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 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 Service 01/06/16 01-16-04
09-16-04
27-16-04
02-16-04
11-16-04
30-16-04
03-16-04
14-16-04
31-16-04
08-16-04
24-16-04
32-16-04
33-16-04Ch. 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 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 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
33-16-10Ch. 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
47-16-01Ch. 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
31-16-09Ch. 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
33-16-15Ch. 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. 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
31-16-21Ch. 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
31-16-20Ch. 1121 Prior Authorization of Hereditary Angioedema (HAE) Agents—
Pharmacy Services07/05/16 01-16-22
09-16-20
27-16-20
02-16-19
11-16-19
30-16-19
03-16-19
14-16-20
31-16-24
08-16-20
24-16-22
32-16-18
33-16-19Ch. 1121 Prior Authorization of Anticoagulants—Pharmacy Services 07/05/16 01-16-20
09-16-18
27-16-18
02-16-17
11-16-17
30-16-17
03-16-18
14-16-18
31-16-22
08-16-18
24-16-20
32-16-16
33-16-17Ch. 1121 Prior Authorization of Cephalosporins and Related Agents—
Pharmacy Services07/05/16 01-16-28
09-16-26
27-16-26
02-16-25
11-16-25
30-16-25
03-16-25
14-16-26
31-16-30
08-16-26
24-16-28
32-16-24
33-16-25Ch. 1121 Preferred Drug List (PDL) Update July 18, 2016—Pharmacy 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
16-16-01Ch. 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
31-16-34Ch. 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
33-16-29Ch. 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
33-17-01Ch. 1121 Prior Authorization of Opiate Dependence Treatments—
Pharmacy Service01/04/17 01-17-02
02-17-01
03-17-01
08-17-02
09-17-02
11-17-01
14-17-01
24-17-01
27-17-01
30-17-02
31-17-03
32-17-01
33-17-02Ch. 1101 1150 Submission of Claims that Require the National Provider Identifier (NPI) of the Ordering, Referring or Prescribing Provider 01/30/17 99-17-02 Ch. 1121 Prior Authorization of Anitparkinson's Agents—Pharmacy Services 01/30/17 01-17-06
09-17-05
27-17-04
02-17-04
11-17-04
30-17-05
03-17-04
14-17-04
31-17-06
08-17-05
24-17-04
32-17-04
33-17-05Ch. 1121 Prior Authorization of Botulinum Toxins—Pharmacy Services 01/30/17 01-17-09
09-17-08
27-17-07
02-17-07
11-17-07
30-17-08
03-17-07
14-17-07
31-17-09
08-17-08
24-17-07
32-17-07
33-17-08Ch. 1121 Prior Authorization of Bronchodilators, Beta Agonists—
Pharmacy Services01/30/17 01-17-10
09-17-09
27-17-08
02-17-08
11-17-08
30-17-09
03-17-08
14-17-08
31-17-10
08-17-09
24-17-08
32-17-08
33-17-09Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—
Pharmacy Services01/30/17 01-17-11
02-17-09
03-17-09
08-17-10
09-17-10
11-17-09
14-17-09
24-17-09
27-17-09
30-17-10
31-17-11
32-17-09
33-17-10Ch. 1121 Prior Authorization of Analgesics, Narcotic Long Acting and Analgesics, Narcotic Short Acting—Pharmacy Service 01/31/17 01-17-04
09-17-03
27-17-02
02-17-02
11-17-02
30-17-03
03-17-02
14-17-02
31-17-04
08-17-03
24-17-02
32-17-02
33-17-03Ch. 1121 Prior Authorization of Analgesics, Non-Narcotic Barbiturate Combinations—Pharmacy Service 01/31/17 01-17-05
09-17-04
27-17-03
02-17-03
11-17-03
30-17-04
03-17-03
14-17-03
31-17-05
08-17-04
24-17-03
32-17-03
33-17-04Ch. 1121 Prior Authorization of Anxiolytics—Pharmacy Services 01/31/17 01-17-07
09-17-06
27-17-05
02-17-05
11-17-05
30-17-06
03-17-05
14-17-05
31-17-07
08-17-06
24-17-05
32-17-05
33-17-06Ch. 1121 Prior Authorization of Bile Salts—Pharmacy Service 01/31/17 01-17-08
09-17-07
27-17-06
02-17-06
11-17-06
30-17-07
03-17-06
14-17-06
31-17-08
08-17-07
24-17-06
32-17-06
33-17-07Ch. 1121 Prior Authorization of Nplate (romiplostim)—Pharmacy Services 01/31/17 01-17-12
02-17-10
03-17-10
08-17-11
09-17-11
11-17-10
14-17-10
24-17-10
27-17-10
30-17-11
31-17-12
32-17-10
33-17-11Ch. 1121 Prior Authorization of Pituitary Suppressive Agents, LHRH—
Pharmacy Services01/31/17 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 Services 01/31/17 01-17-16
02-17-14
03-17-14
08-17-15
09-17-15
11-17-14
14-17-14
24-17-14
27-17-14
30-17-15
31-17-16
32-17-14
33-17-15Ch. 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 Services 04/27/17 01-17-19
02-17-17
03-17-17
08-17-19
09-17-18
11-17-17
14-17-17
24-17-17
27-17-17
30-17-18
31-17-19
32-17-17
33-17-18Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 04/27/17 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
08-17-22Ch. 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 Services 06/07/17 01-17-26
02-17-24
03-17-24
08-17-27
09-17-25
11-17-24
14-17-24
24-17-24
27-17-24
30-17-25
31-17-26
32-17-24
33-17-25Ch. 1121 Prior Authorization of Spinraza (nusinersen)—Pharmacy 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
27-17-26Ch. 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
33-17-30Ch. 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
33-17-27Ch. 1101 1150 Procedure Code Change for Tobacco Cessation Counseling Services 08/07/17 99-17-07 Ch. 1121 Prior Authorization of Intra-Articular Hyaluronates—Pharmacy Services 08/08/17 01-17-33
02-17-28
03-17-28
08-17-34
09-17-31
11-17-28
14-17-28
24-17-29
27-17-29
30-17-29
31-17-33
32-17-28
33-17-32Ch. 1127 1143
1163''Newborn Add'' Feature for COMPASS 08/09/17 01-17-28
33-17-28
47-17-01Ch. 1101 Limited English Proficiency Requirements 08/11/17 99-17-11 Ch. 1101 School-Based ACCESS Program Provider Handbook 11/22/17 35-17-02 Ch. 1121 Prior Authorization of Antibiotics, GI and Related Agents—
Pharmacy Services12/14/17 01-17-35
02-17-30
03-17-30
08-17-37
09-17-34
11-17-30
14-17-31
24-17-31
27-17-32
30-17-31
31-17-36
32-17-30
33-17-35Ch. 1121 Prior Authorization of Analgesics, Opioid Long Acting—Pharmacy Services 12/27/17 01-17-36
02-17-31
03-17-31
08-17-37
09-17-35
11-17-31
14-17-32
24-17-32
27-17-33
30-17-32
31-17-37
32-17-31
33-17-36Ch. 1121 Prior Authorization of Xermelo (telotristat ethyl)—Pharmacy Services 12/27/17 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 Services 12/27/17 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 Services 12/27/17 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 Services 12/14/17 01-17-37
02-17-32
03-17-32
08-17-39
09-17-36
11-17-32
14-17-33
24-17-33
27-17-34
30-17-33
31-17-38
32-17-32
33-17-37Ch. 1163 Hospital Responsibilities Related to the Uncompensated Care Program and Charity Care Plans 12/27/17 01-17-03 Ch. 1121 Prior Authorization of Xenazine (tetrabenazine)—Pharmacy Services 12/27/17 01-17-45
02-17-40
03-17-40
08-17-47
09-17-44
11-17-40
14-17-41
24-17-41
27-17-42
30-17-41
31-17-46
32-17-40
33-17-45Ch. 1121 Prior Authorization of Bone Resorption Suppression and Related Agents—Pharmacy Services 12/27/17 01-17-42
02-17-37
03-17-37
08-17-44
09-17-41
11-17-37
14-17-38
24-17-38
27-17-39
30-17-38
31-17-43
32-17-37
33-17-42Ch. 1121 Prior Authorization of Cytokine and CAM Antagonists—Pharmacy Services 12/27/17 01-17-46
02-17-41
03-17-41
08-17-48
09-17-45
11-17-41
14-17-42
24-17-42
27-17-43
30-17-42
31-17-47
32-17-41
33-17-462018 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 Services 01/08/18 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 Services 01/22/18 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
33-18-05Ch. 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
33-18-03Ch. 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
33-18-02Ch. 1101 School-Based ACCESS Program Provider Handbook 03/14/18 35-18-01 Ch. 1221 Prior Authorization of Opioid Dependence Treatments—Pharmacy Services 04/10/18 01-18-06
02-18-04
03-18-04
08-18-07
09-18-07
11-18-04
14-18-05
24-18-04
27-18-06
30-18-04
31-18-07
32-18-04
33-18-07Ch. 1101 1121
1150Update to Submission of Claims that Require the National Provider Identifier (NPI) of a Medical Assistance Enrolled Ordering, Referring or Prescribing Provider 04/16/18 99-18-06 Ch. 1121 Prior Authorization of Analgesics, Opioid Long Acting—Pharmacy Services 04/26/18 01-18-07
09-18-08
27-18-07
33-18-08
02-18-05
11-18-05
30-18-05
03-18-05
14-18-06
31-18-08
08-18-08
24-18-05
32-18-05Ch. 1121 Prior Authorization of Analgesics, Opioid Short Acting—Pharmacy Services 04/26/18 01-18-05
09-18-06
27-18-05
33-18-06
02-18-03
11-18-03
30-18-03
03-18-03
14-18-04
31-18-06
08-18-06
24-18-03
32-18-03Ch. 1241 2018 Recommended Childhood and Adolescent Immunization Schedule 04/27/18 99-18-05 Ch. 1101 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
33-18-09Ch. 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
31-18-10Ch. 1121 Preferred Drug List (PDL) Update July 23, 2018—Pharmacy Services 07/18/18 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 Services 07/23/18 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 Services07/23/18 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 Services12/12/18 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 Services12/13/2018 01-18-29
02-18-24
03-18-25
08-18-32
09-18-30
11-18-24
14-18-25
24-18-26
27-18-29
30-18-24
31-18-30
32-18-24
33-18-29Ch. 1121 Prior Authorization of Oncology Agents, Oral—Pharmacy Services 12/13/18 01-18-34
02-18-29
03-18-30
08-18-37
09-18-35
11-18-29
14-18-30
24-18-31
27-18-34
30-18-29
31-18-35
32-18-29
33-18-34Ch. 1121 Prior Authorization of Kalydeco (ivacaftor)—Pharmacy Services 12/13/18 01-18-32
02-18-27
03-18-28
08-18-35
09-18-33
11-18-27
14-18-28
24-18-29
27-18-32
30-18-27
31-18-33
32-18-27
33-18-32Ch. 1121 Prior Authorization of Orkambi (lumacaftor/ivacaftor)—Pharmacy Services 12/13/18 01-18-35
02-18-30
03-18-31
08-18-38
09-18-36
11-18-30
14-18-31
24-18-32
27-18-35
30-18-30
31-18-36
32-18-30
33-18-35Ch. 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 Ch. 1243 Updates to Laboratory Services on the Medical Assistance Program Fee Schedule; Prior Authorization for Noninvasive Prenatal Screening (NiPS) 01/02/19 01-19-01
08-19-01
09-19-01
28-19-01
31-19-01
33-19-01Ch. 1121 Prior Authorization of Anticonvulsants—Pharmacy Services 01/18/19 01-19-06
02-19-05
03-19-05
08-19-08
09-19-06
11-19-05
14-19-05
24-19-05
27-19-06
30-19-05
31-19-06
32-19-05
33-19-06Ch. 1121 Preferred Drug List (PDL) Update January 28, 2019—Pharmacy Services 01/18/19 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 Services 01/18/19 01-19-10
02-19-09
03-19-09
08-19-12
09-19-10
11-19-09
14-19-09
24-19-09
27-19-10
30-19-09
31-19-10
32-19-09
33-19-10Ch. 1121 Prior Authorization of Antiparkinson's Agents—Pharmacy Services 01/18/19 01-19-09
02-19-08
03-19-08
08-19-11
09-19-09
11-19-08
14-19-08
24-19-08
27-19-09
30-19-08
31-19-09
32-19-08
33-19-09Ch. 1121 Prior Authorization of Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled—Pharmacy Services 01/18/19 01-19-07
02-19-06
03-19-06
08-19-09
09-19-07
11-19-06
14-19-06
24-19-06
27-19-07
30-19-06
31-19-07
32-19-06
33-19-07Ch. 1121 Prior Authorization of Alpha-1 Proteinase Inhibitors—Pharmacy Services 01/18/19 01-19-08
02-19-07
03-19-07
08-19-10
09-19-08
11-19-07
14-19-07
24-19-07
27-19-08
30-19-07
31-19-08
32-19-07
33-19-08Ch. 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 Services 01/21/19 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
47-19-01Ch. 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 Services 6/27/19 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 Services 7/30/19 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 Services 8/8/19 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 Services 8/8/19 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
33-19-13Ch. 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 Services 9/3/19 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 Services 9/4/19 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 Services 9/4/19 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 Services 9/5/19 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 Services 9/10/19 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 Services 9/10/19 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 Services 9/11/19 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 Services 9/11/19 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 Services 9/16/19 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
31-19-21Ch. 1121 Statewide Preferred Drug List (PDL) Implementation—Pharmacy Services 10/10/19 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 Services 10/16/19 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 Services 10/17/19 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 Services 10/21/19 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 Services 10/21/19 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 Services10/25/19 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 Services 10/30/19 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 Services 10/31/19 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
27-19-92Ch. 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 Services 12/5/19 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 Services12/5/19 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 Services 12/5/19 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 Services12/6/19 01-19-99
02-19-93
03-19-92
08-19-102
09-19-95
11-19-92
14-19-91
24-19-94
27-19-94
30-19-91
31-19-99
32-19-91
33-19-96Ch. 1121 Prior Authorization of Growth Hormones—Pharmacy Services 12/6/19 01-19-109
02-19-103
03-19-102
08-19-112
09-19-105
11-19-102
14-19-101
24-19-104
27-19-104
30-19-101
31-19-109
32-19-101
33-19-106Ch. 1121 Prior Authorization of Analgesics, Opioid Short-Acting—Pharmacy Services 12/6/19 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 Services 12/6/19 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 Services 12/6/19 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 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
56-20-01Ch. 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
33-20-02Ch. 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
31-20-06Ch. 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
33-20-03Ch. 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
31-20-03Ch. 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. 1249 Implementation of Electronic Visit Verification in the FFS and Physical Health Managed Care Delivery Systems 6/11/20 05-20-02
07-20-02Ch. 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
31-20-08GUIDANCE MANUALS:
• Provider Handbook—Physician—updated 10/2017
• Provider Handbook—Dentist—updated 10/2017
• Provider Handbook—Podiatrist—updated 10/2017
• Provider Handbook—Medical Supplier—updated 10/2017
• Provider Handbook—Short Procedure Unit/Ambulatory Surgical Center—updated 10/2017
• Provider Handbook—Chiropractor—updated 10/2017
• Provider Handbook—Birth Centers—updated 10/2017
• Provider Handbook—Independent Medical/Surgical Clinic—updated 10/2017
• Provider Handbook—Inpatient Hospital (Encompasses provider types General Hospital, Rehabilitation Hospital, Private Mental Hospital, State Mental Hospital and Extended Acute Psychiatric Care—updated 10/2017
• Provider Handbook—Outpatient Hospital (Encompasses provider types General Hospital, and Rehabilitation Hospital)—updated 10/2017
• Provider Handbook—Optometrist—updated 10/2017
• Provider Handbook—Independent Laboratory—updated 10/2017
• Provider Handbook—Ambulance Company—updated 10/2017
• Provider Handbook—Pharmacy—updated 10/2017
• Provider Handbook—Portable X-Ray Provider—updated 10/2017
• Provider Handbook—Renal Dialysis Center—updated 10/2017
• Provider Handbook—Funeral Director—updated 10/2017
• Provider Handbook—Home Health Agency—updated 10/2017
• Provider Handbook—Rural Health Clinic—updated 10/2017
• Provider Handbook—Drug and Alcohol Clinic—updated 10/2017
• Provider Handbook—Outpatient Psychiatric Clinic—updated 10/2017
• Provider Handbook—Family Planning Clinic—updated 10/2017
• Provider Handbook—Midwives—updated 10/2017
• Provider Handbook—Psychiatric Partial Hospitalization Facility—updated 10/2017
• Provider Handbook—Hospice—updated 10/2017
• Provider Handbook—Psychologist—updated 10/2017
• Provider Handbook—Comprehensive Outpatient Rehabilitation Facility—updated 10/2017
• Provider Handbook—Physical Therapist—updated 10/2017
• Provider Handbook—Certified RN Anesthetist—updated 10/2017
• Provider Handbook—Certified RN Practitioner—updated 10/2017
• Provider Handbook—Early Periodic Screening, Diagnosis and Treatment (EPSDT) Provider updated 10/2017
• Provider Handbook—Nutritionist—updated 10/2017
• Provider Handbook—PA Department of Aging (PDA) Waiver—updated 10/2017
• Provider Handbook—COMMCARE Waiver updated 10/2017
• Medical Assistance Transportation Program—Standards and Guidelines updated 11/2016PROVIDER QUICK TIPS
• # 11: 11—The Eligibility Verification System (EVS) (Updated November 7, 2019)
• # 85: Department of Human Services (DHS) Breast and Cervical Cancer Prevention and Treatment Program (updated February 2020)
• # 121: Certificate Renewal Required for Medical Assistance (MA) Providers Dispensing Hearing Aid Supplies (revised February 2020)
• # 176: Presumptive Eligibility for Pregnant Women—2020 Income Limits
• # 207: MA Program Fee Schedule Updates for Act 62 Procedure Codes (Updated May 26, 2020)
• # 223: Availability of the Provider Directory on the Department of Human Services Website—June 20, 2019
• # 225: The Auditor General is conducting performance audits—March 2020
• # 226: Version 37 of all Patient Refined-Diagnosis Related Group (APR DRG) Implementation—March 2020
• # 227: Provider Enrollment Updating Documentation Requirements—March 2020
• # 228: ICD-10-CM Official Coding Guidelines Related to COVID-19—March 2020
• # 229: Telemedicine Guidelines Related to COVID-19—March 2020
• # 230: COVID-19 Response: Pharmacies May Override Early Refill Alerts for Medications—April 7, 2020
• # 231: Directions to bypass the prior authorization requirements for CT Scans of the Chest for COVID-19 patients—March 2020
• # 232: Billing Guidance for Alternative Screening Sites Related to COVID-19—March 19, 2020
• # 233: Waiver of Prudent Pay during COVID-19 emergency—March 20, 2020
• # 236: Hydroxychloroquine Quantity Limits—April 1, 2020
• # 237: Teledentistry Guidelines Related to COVID-19 for Dentists, Federally Qualified Health Centers and Rural Health Clinics—April 7, 2020
• # 238: 90-Day Supplies of Medications—COVID-19—April 7,2020
• # 239: Short-Acting beta agonist metered dose inhalers temporarily added to Statewide Preferred Drug List—April 7, 2020
• # 240: Provider enrollment and revalidation changes during the COVID-19 emergency—April 9, 2020
• # 241: Prior Authorization Changes in the Medical Assistance Program for Certain Services during COVID0-19 Emergency Disaster—April 9, 2020
• # 242: Telemedicine Guidelines Related to COVID-19—April 9, 2020
• # 243: Use of the CR Modifier and DR Condition Code for COVID-19 Disaster/Emergency Related Claims—April 16, 2020
• # 244: MA Eligibility During COVID-19 Emergency Disaster Declaration—April 17, 2020
• # 245: All Patient Refined-Diagnosis Related Group (APR-DRG) to be Updated with COVID-19 Billing Codes—April 30, 2020
• # 246: Rescinding Prior Guidance on Elective Services—May 7, 2020
• # 247: Nonemergency Ambulance Transportation—May 8, 2020
• # 248: DexCom Continuous Glucose Monitoring Products Coverage—May 19, 2020
• # 249: New MA ACCESS Card—June 24, 2020OTHER:
• PA 67 Section 1915(b) Waiver
OTHER COVID-19 GUIDANCE:
• Providing Direct Services in the School-Based ACCESS Program (SBAP) During the COVID-19 Emergency—May 28, 2020
• OMAP Announcement 05-08-2020-02: MATP Consumer Notice—May 8, 2020
• OMAP Announcement 05-08-2020-01: MATP Guidance during the COVID-19 Pandemic—May 8, 2020
• Request for State Plan Amendments Related to Novel Coronavirus Disease (COVID-19) National Emergency/Public Health Emergency—April 22, 2020
• OMAP Announcement 04-07-2020-02: MATP Mileage Reimbursement Notice—April 7, 2020
• Providing Direct Services via Telemedicine in the School-Based ACCESS Program (SBAP) During the COVID-19 Emergency—April 3, 2020
• Approval of Federal Section 1135 Waiver Request—March 27, 2020
• 1135 Waiver Request Checklist—March 25, 2020
• Medical Assistance (MA) Program Coverage of 2019-Novel Coronavirus Testing and Related Services Frequently Asked Questions (FAQs)—March 24, 2020
[Continued on next Web Page]
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