Pharmacy Prior Authorization General Requirements

Welcome to the Pharmacy Services prior authorization site. If you cannot find the information you need, please Contact DHS.

Index of Subjects

  1. Prescriptions That Require Prior Authorization
  2. 5-Day Supplies Without Prior Authorization
  3. Initiating the Prior Authorization Request
     
    1. Who May Initiate the Request
    2. Where and When to Call
  4. Information and Supporting Documentation Required for the Prior Authorization Review
  5. Documentation Supporting the Need for a Prescription That Requires Prior Authorization
  6. Review of Documentation for Medical Necessity
  7. Automated Prior Authorization Approvals
  8. Clinical Review Process
  9. Dose and Duration of Therapy
  10. Timeframe of Review
  11. Notice of Decision
  12. Prior Authorization Number
  13. Denials

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  1. Prescriptions That Require Prior Authorization
     
    Prescriptions that meet any of the following conditions must be prior authorized:
    1. A prescription for a non-preferred drug. See Preferred Drug List (PDL) Chapter for the list of preferred drugs and Chapter relating to the specific therapeutic class of drugs on the PA PDL website.
    2. A prescription for a preferred drug as set forth in the Chapter relating to the specific therapeutic class of drugs.
    3. A prescription for a drug when the prescribed quantity exceeds the quantity limit. See Quantity Limits for the list of drugs subject to quantity limits and the quantity limits.
    4. A prescription for a drug within a therapeutic class of drugs not included in the (PDL) that requires prior authorization. See the Chapter relating to the specific drug or therapeutic class of drugs.
    5. A prescription for a multisource brand name drug that has an A-rated generic equivalent available for substitution.

      EXCEPTIONS: Prescriptions exempt from prior authorization are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.

      GRANDFATHER PROVISION: Provisions for grandfathering certain prescriptions in order to avoid any potential disruption in therapy are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.

      If the PROMISe Point-Of-Sale On-Line Claims Adjudication System indicates that a prior authorization is required and the prescription or the refill has not been prior authorized, the pharmacist should notify the recipient and the prescriber that the prescription now requires prior authorization.

  2. 5-Day Supplies Without Prior Authorization
     
    The Department will allow the pharmacist to dispense a 5-day supply of the prescribed medication without prior authorization if, in the professional judgment of the pharmacist, the recipient has an immediate need for the medication. In these situations, the pharmacist may dispense a 5-day supply of the prescribed medication without prior authorization, unless the pharmacist determines that taking the prescribed medication, either alone or along with other medication(s) that the recipient may be taking, would jeopardize the health and safety of the recipient.
     
  3. Initiating the Prior Authorization Request

    1. Who May Initiate the Request
       
      The prescriber must request the prior authorization.
       
      The procedures for initiating the request are included for the pharmacy’s information to assist the pharmacist in guiding non-participating or out-of-state prescribers on the procedures to requesting prior authorization. Pharmacists may also refer prescribers to the Department’s Web site section regarding the Fee-For-Service Pharmacy Program for prior authorization procedures.
       
    2. Where and When to Call
       
      The MA Fee-for-Service Program Pharmacy Call Center accepts requests for prior authorization at 1-800-537-8862 Option 1, between 8 a.m. and 4:30 p.m., Monday through Friday.
       
      THE PHARMACY SHOULD NOT CONTACT THE PRIOR AUTHORIZATION UNIT FOR APPROVAL TO FILL THE PRESCRIPTION. THIS TELEPHONE NUMBER IS RESERVED FOR PRESCRIBERS ONLY.
    3. Initiating the Request by FAX
       
      The prescribing provider can locate a copy of the appropriate Prior Authorization Form for the medication or class of drugs that require prior authorization on the Pharmacy Services website, Prior Authorization Fax Forms.
       
      The prescribing provider must submit the completed, signed and dated Prior Authorization Form and the required supporting documentation of medical necessity to the Fax number printed on the form, 1-866-327-0191.
  4. Information and Supporting Documentation Required for the Prior Authorization Review
     
    The information required at the time prior authorization is requested includes the following:

    1. The name and ACCESS card number of the recipient.
    2. The prescriber’s license number.
    3. The specifics of the prescription, i.e., drug, strength, quantity, directions, days supply, duration.
    4. Clinical information to support the medical necessity for the medication.
    5. Diagnosis Code(s) or diagnosis.
  5. Documentation Supporting the Need for a Prescription That Requires Prior Authorization
     

    The clinical information provided during the course of the review must also be verifiable within the patient’s medical record. Upon retrospective review, the Department may seek restitution for the payment of the prescription and any applicable restitution penalties from the prescriber if the medical record does not support the medical necessity for the prescription. (See 55 Pa. Code § 1101.83(b)).

  6. Review of Documentation for Medical Necessity
     

    In evaluating a request for prior authorization of a prescription that requires prior authorization, the determination of whether the requested prescription is medically necessary will take into account the guidelines set forth in the chapter relating to the specific therapeutic class of drugs and/or the specific requirement for prior authorization.

  7. Automated Prior Authorization Approvals
     

    When the PROMISe Point-Of-Sale On-Line Claims Adjudication System can verify that the recipient has a record that documents medical necessity for a prescription that requires prior authorization, the request will be automatically approved. Automated Prior Authorization Approvals are noted in each Chapter relating to the specific therapeutic class of drugs or the specific requirement for prior authorization.

  8. Clinical Review Process
     

    Prior authorization personnel will review the request for prior authorization and apply the clinical guidelines to assess the medical necessity of the prescription. If the reviewer determines that the request for prior authorization of a prescription meets the medical necessity guidelines, the reviewer will prior authorize the prescription. The reviewer may request documentation from the medical record to assess medical necessity. (See 55 PA Code § 1101.51(d) and (e)). If the reviewer is unable to determine medical necessity, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. The physician reviewer may request documentation from the medical record to determine medical necessity. (See 55 PA Code § 1101.51(d) and (e)). Such a request for prior authorization may be approved when, in the professional judgment of the physician reviewer, the services are medically necessary to meet the medical needs of the recipient.

  9. Dose and Duration of Therapy
     

    The Department will consider requests to authorize multiple refills for a recipient when, in the professional judgment of the reviewer, treatment for the condition is expected to be ongoing. Multiple refills will not exceed six (6) months or five (5) refill supply, which ever comes first, from the time of the original filling of the prescription. (See 55 Pa Code § 1121.53(c)).

  10. Timeframe of Review
     

    The Department will respond to requests for prior authorization within 24 hours of receiving all information reasonably necessary to make a decision of medical necessity.

  11. Notice of Decision
     

    The Department will notify the prescribing provider by return telephone call or fax indicating whether the requet for prior authorization is approved or denied. The Department will also send a written notice of approval or denial of a request for prior authorization to the prescribing provider and the recipient.

  12. Prior Authorization Number
     

    If the Department approves a request for prior authorization, a 10-digit prior authorization number will be issued. This number should be written on the prescription and in the medical record in the event that the prescriber needs to later refer to the number for the patient or pharmacy.

  13. Denials
     

    If the request to approve a prescription that requires prior authorization is denied or approved other than as requested, the recipient has the right to appeal the Department’s decision. The recipient has 30 days from the date of the prior authorization notice to submit the appeal in writing to the address listed on the notice. If the recipient has been receiving the drug that is being reduced, changed, or denied and an appeal is hand-delivered or postmarked within 10 days of the date of the notice, the Department will authorize the prescription for the drug until a decision is made on the appeal.