Pharmacy Prior Authorization
Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or which have been indicated as requiring prior authorization.
For more information on the pharmacy prior authorization process, call the Pharmacy Services department at 1-800-588-6767.
Important payment notice
Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Effective January 1, 2018, any claim submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.
To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.
How to submit a request for pharmacy prior authorization
Call the Pharmacy Services department at 1-800-588-6767. If it’s outside of normal business hours, you can also call Member Services at 1-800-521-6860.
You can fax your prior authorization request form (PDF) to 1-215-937-5018.
Prior authorization criteria
Many medicines have specific requirements and conditions that must be met to receive prior authorization. Save time by viewing a list of medications and their prior authorization criteria (PDF) before submitting your request.
Specialty and injectable request forms
Specialty drugs include unusually high-cost oral, inhaled, injectable, and infused pharmaceuticals prescribed for a relatively narrow spectrum of diseases and conditions.
To initiate a request for specialty or injectable drugs administered in a physician’s office, or for injectable medications dispensed through network specialty or retail pharmacies for patient self-administration, use one of the drug- or class-specific prior authorization request forms below.
The form must be completed in its entirety and faxed to the Specialty Drug Management Program at 1-215-937-5018. Failure to submit all requested information could result in denial of coverage or a delay of approval as the result of insufficient information.