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 1-866-907-7088.
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
Save time by submitting all your pharmacy prior authorization requests online. Get started at our online prior authorization request form or learn more in our tutorial.
Call the Pharmacy Services department at 1-866-907-7088.
You can fax your prior authorization request form (PDF) to 1-855-851-4058.
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.
Drug- and drug class-specific prior authorization forms
- Opioid containing products (PDF)
- Opioid dependence products request form (PDF)
- Oral antipsychotics request form (PDF)
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 1-855-851-4058. Failure to submit all requested information could result in denial of coverage or a delay of approval as the result of insufficient information.
- Forteo® , Boniva® Injection, and Reclast® request form (PDF)
- Fuzeon® medication history form (PDF)
- Fuzeon® prior authorization procedure and required information form (PDF)
- Growth hormone request form (PDF)
- Hemophilia medication request form (PDF)
- Hepatitis C treatment request form (PDF)
- Hepatitis C prior authorization criteria (PDF)
- Hyaluronic acid derivates request form (PDF)
- Infusible biological medications prior authorization request form (PDF)
- Ixempra physician request form (PDF)
- Juxtapid/Kynamro request form (PDF)
- Kuvan request form (PDF)
- Lemtrada request form (PDF)
- Long-acting injectable atypical antipsychotics request form (PDF)
- Office administered chemotherapy coverage determination form (PDF)
- Oral oncology medications request form (PDF)
- Physician request form for gonadotropin releasing hormone agonists (GNRH) (PDF)
- Procrit® request form (PDF)
- Self-injectable biological for treating arthritis request form (PDF)
- Self-injectable biological for treating psoriasis, psoriatic arthritis, and ankylosing spondylitis (PDF)
- Serostim® request form (PDF)
- Synagis® request form (PDF)