DHS COVID-19 PROVIDER RESOURCES // OMAP
Medical Assistance Bulletin: Pharmacy Services for Medical Assistance
Beneficiaries Related to the COVID-19 Public
Effective: March 1, 2020; Issued: May 27, 2020
Important Reminder: All providers must revalidate the Medical Assistance (MA) enrollment of each service location every five years. Providers should log into PROMISe™ to check the revalidation dates of each service location and submit revalidation applications at least 60 days prior to the revalidation dates. Enrollment (revalidation) applications may be found at https://www.dhs.pa.gov/providers/Providers/Pages/PROMISeEnrollment.aspx.
The purpose of this bulletin is to advise providers of changes made by the Department
of Human Services (Department) to Medical Assistance (MA) pharmacy services to ensure MA
beneficiaries maintain access to needed services during the COVID-19 public health
This bulletin applies to all licensed pharmacies and prescribers enrolled in the MA
program, including the Fee-for-Service (FFS) delivery system and the MA managed care
organizations (MCOs) in Physical Health HealthChoices and Community HealthChoices.
On March 6, 2020, Governor Tom Wolf issued a public health emergency declaration in
response to the presence of COVID-19 in Pennsylvania. On March 13, 2020, COVID-19 was
declared a nationwide emergency under the Stafford Act, retroactive to March 1, 2020.
*01-20-07 09-20-07 27-20-04 33-20-04 02-20-02 11-20-01 30-20-01
03-20-02 14-20-03 31-20-07 08-20-10 24-20-03 32-20-01
The Department suspended copayments effective with dates of service on and after March 1, 2020, for testing services (including in vitro diagnostic products), testing-related services, and treatments for COVID-19, including vaccines, specialized equipment and therapies (including drugs).
MA copayments are also suspended for the following drugs/drug categories, as they may be used in the treatment of COVID-19:
- Antihistamines (Second Generation)
- Anti-infectives • Asthma/COPD
- Ophthalmic Antihistamines/Decongestants
- Ophthalmic Lubricants
- Oral NSAIDs
Copayment exemptions for COVID-19 treatment-related outpatient drugs/drug classes
listed above were added to the FFS (ACCESS) online claims system on April 22, 2020.
Cough and Cold Medications for Adults Over the Age of 21 Years
The Department will pay for prescriptions for cough and cold medications for MA
beneficiaries 21 years of age and older beginning with dates of service on and after March 1, 2020.
Prior to the public health emergency, the Department was already paying for prescribed cough
and cold medications for MA beneficiaries under 21 years of age. The allowance of payment
for cough and cold medications for MA beneficiaries over the age of 21 will remain in effect for
the duration of the public health emergency declaration authorized by the president related to
the COVID-19 virus.
On March 28, 2020, the United States Food and Drug Administration issued an
Emergency Use Authorization that allows individuals with COVID-19 to be treated with
hydroxychloroquine. In an effort to prevent potential shortages and stockpiling of
hydroxychloroquine, thresholds for prior authorization apply for hydroxychloroquine:
- Prescriptions with a quantity greater than 4 tablets per day require prior
- Prescriptions for a supply greater than 10 days require prior authorization.
NOTE: In an effort to prevent gaps in care for non-COVID-19 patients prescribed
hydroxychloroquine, approvals will be automated at the pharmacy point-of-sale for medically
accepted non-COVID-19 diagnoses. Prior authorization overrides will be issued for current
users of hydroxychloroquine for non-COVID-19 related diagnoses. These beneficiaries will be
able to obtain their usual day supply at the pharmacy. Prior authorization requests for longer
durations of treatment for COVID-19 will be reviewed for medical necessity and approved
based on current medical literature and specialist/prescriber input. Prior authorization
approvals will not be issued for COVID-19 prophylaxis.
The above limits align with the dosing found in current medical literature for both
COVID-19 and non-COVID-19 indications. The Department will continue to monitor emerging
medical literature and treatment guidelines and will adjust the above limits as necessary.
Changes to Statewide Preferred Drug List (PDL) for Albuterol Metered Dose Inhalers
Albuterol HFA is the preferred short-acting beta agonist metered dose inhaler (MDI) on
the Pennsylvania MA Statewide PDL. The Department is aware of ongoing supply issues with
albuterol HFA MDIs. Effective April 1, 2020, additional short-acting beta agonist MDIs are
preferred on the Statewide PDL, as set forth below, and will remain preferred until an adequate
supply of albuterol HFA is available in the marketplace.
Bronchodilators, Beta Agonist
|Preferred Agents||Non-Preferred Agents|
- Albuterol HFA QL
- Albuterol Nebulizer Concentrate Solution, Vial
- Albuterol Syrup
- Serevent DiskusPA, QL
- Albuterol Tablet
- Albuterol ER Tablet
- Arcapta Neohaler QL
- Brovana Vial QL
- ** Levalbuterol HFA QL
- Levalbuterol Nebulizer Concentrate Solution, Vial QL
- Metaproterenol Syrup, Tablet
- Perforomist Solution QL
- ** Proair HFA QL
- ** Proair Respiclick QL
- ** Proventil HFA QL
- Striverdi Respimat QL
- Terbutaline Tablet
- ** Ventolin HFA QL
- ** Xopenex HFA QL
- Xopenex Nebulizer
- Concentrate Solution, Vial QL
**Effective April 1, 2020, products indicated with ** in the list
above will be PREFERRED and remain preferred for the
duration of albuterol HFA shortages.
Sublocade Prior Authorization
Sublocade (buprenorphine extended-release) injection is a once-monthly injection
indicated for the treatment of opioid use disorder. It is a preferred medication in the Opioid
Dependence Treatments class on the Pennsylvania MA Statewide PDL. The prior
authorization guidelines for Opioid Dependence Treatments have been revised to indicate that
prescriptions for Sublocade injection that do not exceed the quantity limit no longer require
Claims for medications for FFS beneficiaries should be billed as pharmacy claims using
the standard NCPDP, 837 Professional, or internet formats.
For the duration of the public health emergency declaration authorized by the president
related to the COVID-19 virus, the following apply:
- Dispensing providers and pharmacies may dispense a 90-day supply of a
medication pursuant to a valid prescription that is written for at least a 90-day
- Claims billed to Fee-for-Service on or after April 22, 2020 for COVID-19
treatment-related outpatient drugs/drug classes listed above will return a
copayment of $0 at the point-of-sale. MA providers may not collect a copayment
for these medications and the amount of the copayment will not be deducted
from the amount paid to the provider. For claims billed to FFS from March 1,
2020, through April 21, 2020, for COVID-19 treatment-related outpatient
drugs/drug classes listed above pharmacies should refund copayments paid by
the beneficiary and resubmit the claims to receive the full payment amount from
- Claims for cough and cold medications pursuant to a valid prescription for adults
over the age of 21 years will pay at the point-of-sale.
- If a pharmacy is unable to obtain a generic albuterol HFA product due to a
product shortage, a corresponding brand name product may be dispensed with a
DAW code of 1. Claims submitted for ProAir HFA, Proventil HFA, and Ventolin
HFA that are within the quantity limits will pay at the point-of-sale. Claims
submitted for levalbuterol HFA that are within the quantity limits will pay at the
- Claims submitted for Sublocade that are within the quantity limits will pay at the
Providers can contact the Department’s Pharmacy Call Center for assistance at 1-800
537-8862 option 2, then option 2.
The procedures for prescribers to request prior authorization of prescriptions that
exceed the quantity and/or duration limits are located in SECTION I of the Prior Authorization
of Pharmaceutical Services Handbook.
The Physical Health HealthChoices and Community HealthChoices MCOs are required
to implement the same changes implemented in the FFS delivery system for the duration of
the public health emergency declaration authorized by the president related to the COVID-19
virus. The procedures to submit claims or request prior authorization for beneficiaries in the
MCOs may differ from those for beneficiaries in the FFS delivery system and are specific to
each MCO. Providers should contact the MCOs for MCO-specific information.
Information on MA Program coverage related to COVID-19 can be found on the
Department of Human Services website at www.dhs.pa.gov/providers/Providers/Pages/Coronavirus-2020.aspx.
The Pennsylvania Department of Health has a dedicated page for COVID-19 that
provides regular updates at www.health.pa.gov/topics/disease/coronavirus/Pages/Coronavirus.aspx.
The Pennsylvania MA Statewide PDL can be viewed at www.papdl.com.
Prior authorization guidelines for Opioid Dependence Treatments can be found on the
MCO websites and the Department’s website at www.dhs.pa.gov/providers/PharmacyServices/Pages/Clinical-Guidelines.aspx.