Fee-for-Service Pharmacy Prior Authorization General Requirements and Procedures

These requirements and procedures for requesting prior authorization should be followed to ensure accurate and timely processing of prior authorization requests. Providers may obtain additional information by calling the Pharmacy Services call center at 1-800-537-8862 during the hours of 8 AM to 4:30 PM Monday through Friday.

Prescriptions That Require Prior Authorization

Prescriptions that meet any of the following conditions must be prior authorized 

• A prescription for a non-preferred drug. See the Preferred Drug List (PDL) for the list of drug classes that are included in the PDL and the preferred and non-preferred drugs in each PDL drug class (e.g., Beta Blockers, VMAT2 Inhibitors, etc.).
• A prescription for a preferred drug as indicated in the Prior Authorization Clinical Guidelines relating to the corresponding PDL class of drugs.
• A prescription for a drug not included in the PDL that requires prior authorization. Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or therapeutic class of drugs (e.g., Synagis, Alpha-1 Proteinase Inhibitors, Immune Globulins).
• A prescription for a drug when the prescribed quantity, dose per day, or duration of therapy exceeds the quantity limit, daily dose limit, or duration of therapy limit established by the Department of Human Services ("the Department"). See Quantity Limits/Daily Dose Limits for the list of drugs subject to quantity limits/daily dose limits/duration of therapy limits and the corresponding quantity limit/daily dose limit/duration of therapy limit for each drug.
• A prescription for a multisource brand name drug that has an FDA-approved A-rated generic equivalent available for substitution unless the multisource brand name drug is designated as preferred on the PDL.
• A prescription for a beneficiary of a certain age when the prescribed drug is subject to age restrictions. Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs for applicable age restrictions and requirements.
• A prescription for a drug that has the same mechanism of action as another drug that the beneficiary recently received based on the beneficiary's claims history in the Department's Point-of-Sale Online Claims Adjudication System (i.e., therapeutic duplication). Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs for therapeutic duplication requirements.
• A prescription for an early refill. An early refill is defined as a request for a refill when more than 15% of a previous fill of the same drug and strength should remain based on the directions and quantity of the previously dispensed prescription.

5-Day Supplies Without Prior Authorization

If a prescription requires prior authorization and the beneficiary has an immediate need for the prescribed drug, the Department will allow the pharmacy to dispense a 5-day supply of the drug without prior authorization at the discretion of the dispensing pharmacist. Pharmacists should use their professional judgment to determine if the beneficiary has an immediate need for the drug. Pharmacists may choose to not fill a 5-day supply of a drug if the pharmacist determines that taking the drug alone or in combination with the beneficiary's other drugs may jeopardize the health and safety of the beneficiary.

When filling a prescription for a 5-day supply, the dispensing pharmacy should bill the prescription for a quantity sufficient for a 5-day supply based on the prescribing provider's directions. The pharmacy must enter a "3" in the Level of Service field in the pharmacy dispensing system.

Five-day supplies may not be dispensed in a limited number of circumstances. Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs for more information.

Initiating the Prior Authorization Request

Who May Initiate a Request

With the exception of early refill requests, prior authorization requests must be initiated by the prescribing provider. Pharmacies may call the Pharmacy Services call center at 1-800-537-8862 to request an override for early refill denials.

Initiating a Request by Phone

The Pharmacy Services call center accepts requests for prior authorization over the phone at 1-800-537-8862 between 8 AM and 4:30 PM Monday through Friday. Clinical documentation supporting the medical necessity of the prescription must be submitted to the Department for all prior authorization requests. Clinical documentation for requests initiated by phone should be faxed to 717-265-8289. This fax number will also be provided by the Pharmacy Services coordinator during the call.

Initiating a Request by Fax

If the prescribing provider prefers to initiate a prior authorization request by fax, the provider may download the appropriate prior authorization fax form for the drug or class of drugs that require prior authorization from the Pharmacy Services Prior Authorization Fax Forms website. The provider may also call the Pharmacy Services call center at 1-800-537-8862 to request the appropriate prior authorization fax form that will be faxed to the provider's office.

The prescribing provider must submit the completed, signed, and dated prior authorization fax form and the required supporting clinical documentation of medical necessity by fax to 1-866-327-0191. This fax number is also printed on the top of each prior authorization fax form.

Basic Information Required for the Prior Authorization Request

The basic information required at the time prior authorization is requested includes the following:

• The name and Medical Assistance ID number (i.e., ACCESS card number) of the beneficiary.
  
• The name and phone number of the contact person at the prescriber's office.
• The prescriber's specialty or field of practice.
• The prescriber's office address, phone number, and fax number.
• The prescriber's state license number and NPI number.
• The specifics of the prescription, including drug name, strength, and formulation (e.g., capsule, inhalation, injection, etc.); quantity written; directions for use; days' supply of the prescription; and duration of therapy requested.
• The beneficiary's diagnosis(es) or condition(s) being treated and corresponding diagnosis code(s).
  

Clinical Documentation Supporting the Medical Necessity of a Prescription That Requires Prior Authorization

Prescribing providers must submit clinical documentation to support the medical necessity of the requested drug for the beneficiary. Examples of appropriate clinical documentation include chart or clinic notes, laboratory test results, and diagnostic test results (e.g., radiographs, MRIs, etc.). Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or corresponding class of drugs for details regarding the information required to process the prior authorization request.

The clinical information submitted with the prior authorization request must be verifiable within the beneficiary'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 of the drug. (See 55 Pa. Code § 1101.83(b)).

Submitting the Prior Authorization Request

For prior authorization requests initiated by phone, the prescribing provider must submit the required supporting clinical documentation of medical necessity by fax to 717-265-8289. This fax number will also be provided by the Pharmacy Services coordinator over the phone when initiating the request.

For prior authorization requests initiated by fax, the prescribing provider must submit the completed, signed, and dated Prior Authorization Form and the required supporting clinical documentation of medical necessity by fax to 1-866-327-0191. This fax number is also printed on the top of each prior authorization fax form.

Clinical Review Process

Prior authorization personnel will review the request for prior authorization and apply the Prior Authorization Clinical Guidelines relating to the specific drug or corresponding class of drugs to assess the medical necessity of the requested drug. If the reviewer determines that the request meets the prior authorization guidelines, the reviewer will prior authorize the prescription. The reviewer may request additional documentation from the beneficiary's medical record to assess medical necessity. (See 55 PA Code § 1101.51(d) and (e)).

If the reviewer is unable to determine medical necessity or if the request does not meet the prior authorization guidelines, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. The physician reviewer may request additional documentation from the beneficiary's medical record to assess 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 beneficiary.

Automated Prior Authorization Approvals

A prescription for a drug that requires prior authorization with a prescribed quantity that does not exceed the quantity limit established by the Department will be automatically approved when the Department's Point-of-Sale On-Line Claims Adjudication System verifies a record of a paid claim(s) verifying that the guidelines to determine medical necessity have been met. Automated Prior Authorization Approvals and Guidelines to Determine Medical Necessity are noted in the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs.

Dose and Duration of Therapy

The Department will consider requests to authorize multiple fills for a beneficiary when, in the professional judgment of the reviewer and in accordance with the Dose and Duration of Therapy in the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs, treatment for the condition is expected to be ongoing.

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.

Notice of Decision

The Department will notify the prescribing provider by return telephone call or fax indicating whether the request 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 beneficiary by mail.

Denials and Appeals

If the request to approve a prescription that requires prior authorization is denied or approved other than as requested, the beneficiary has the right to appeal the Department's decision. The beneficiary 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 beneficiary 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. Refer to the Hearings and Appeals Process for more information.