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Department of Human Services
Menu
Services
Services
Assistance
Children
Disabilities & Aging
Mental Health in PA
Mass Care and Emergency Assist
Other Services
Find a Document
Find a Document
For Providers
Publications
The Impact
Forms
About
About
DHS Online Services
DHS Leadership
DHS Facilities
Data Dashboards
Priorities
Fraud and Abuse
ECM Enterprise Case Management
Contact Us
Contact Us
Helpful Phone Numbers
Feedback Form
DHS Offices
County Assistance Offices
DHS Press Office
Text Messaging
For Providers
For Providers
Sort by Industry
Clearances
Licensing
FAQs
Apply for Benefits
COMPASS
Report Fraud & Abuse
Licensing
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SNAP
Contact Us
Medicaid & CHIP Renewals
Department of Human Services
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Pharmacy Services
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Pharmacy Services Prior Authorization Clinical Guidelines
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Pharmacy Services Prior Authorization Clinical Guidelines
Related Links
FFS Prior Authorization General Requirements
FFS Prior Authorization Fax Forms
Statewide Preferred Drug List (PDL)
Statewide PDL Prior Authorization Guidelines
Fee-for-Service Non-PDL Prior Authorization Guidelines
Acne Agents, Oral
Acne Agents, Topical
Alcohol Use Disorder Agents
Alzheimer’s Agents
Analgesics, Non-Opioid Barbiturate Combinations
Analgesics, Opioid Long-Acting
Analgesics, Opioid Short-Acting
Androgenic Agents
Angiotensin Modulator Combinations
Angiotensin Modulators
Antianginal Agents
Antibiotics, GI and Related Agents
Antibiotics, Inhaled
Antibiotics, Topical
Anticoagulants
Anticonvulsants
Antidepressants, Other
Antidepressants, SSRIs
Antiemetics/Antivertigo Agents
Antifibrotic Respiratory Agents (formerly Idiopathic Pulmonary Fibrosis (IPF) Agents)
Antifungals, Oral
Antifungals, Topical
Antihemophilia Agents
Antihistamines, Minimally Sedating
Antihypertensives, Sympatholytic
Antihyperuricemics
Antimalarials
Antiparasitics, Topical
Antiparkinson’s Agents
Antipsoriatics, Oral
Antipsoriatics, Topical
Antipsychotics
Antivirals, CMV
Antivirals, Herpes
Antivirals, Influenza
Anxiolytics
Benign Prostatic Hyperplasia (BPH) Treatments
Beta Blockers
Bile Salts
Bladder Relaxant Preparations
Blood Glucose Meters and Test Strips
Bone Density Regulators
Botulinum Toxins
Bronchodilators, Beta Agonists
Calcium Channel Blockers
Cephalosporins
Colony Stimulating Factors
Contraceptives, Oral
Contraceptives, Other
COPD Agents
Cytokine and CAM Antagonists
Dry Eye Treatments (formerly Ophthalmics, Immunomodulators)
Dupixent (dupilumab)
Enzyme Replacements, Gaucher Disease
Epinephrine, Self-Injected
Erythropoiesis Stimulating Agents
Estrogens
Fluoroquinolones, Oral
GI Motility, Chronic Agents
Glucocorticoids, Inhaled
Glucocorticoids, Oral
Growth Hormones
H. Pylori Treatments
Hematopoietic Mixtures (formerly Iron, Oral)
Hepatitis B Agents
Hepatitis C Agents
Hereditary Angioedema (HAE) Agents
Histamine 2 Receptor Blockers
HIV/AIDS Antiretrovirals
Hypoglycemia Treatments
Hypoglycemics, Alpha-Glucosidase Inhibitors
Hypoglycemics, Incretin Mimetics/Enhancers
Hypoglycemics, Insulin and Related Agents
Hypoglycemics, Meglitinides
Hypoglycemics, Metformins
Hypoglycemics, SGLT2 Inhibitors
Hypoglycemics, Sulfonylureas
Hypoglycemics, TZDs
Immunomodulators, Atopic Dermatitis
Immunomodulators, Topical
Immunosuppressives, Oral
Intra-Articular Hyaluronates
Intranasal Rhinitis Agents
Iron Chelating Agents
Iron, Parenteral
Leukotriene Modifiers
Lipotropics, Other
Lipotropics, Statins
Local Anesthetics, Topical
Macrolides
Macular Degeneration Agents
Methotrexate
Migraine Acute Treatment Agents
Migraine Prevention Agents
Monoclonal Antibodies (MABs) – Anti-IL, Anti-IgE, Anti-TSLP
Multiple Sclerosis Agents
Neuropathic Pain Agents
NSAIDs
Obesity Treatment Agents
Oncology Agents, Breast Cancer
Oncology Agents, Oral
Ophthalmics, Allergic Conjunctivitis
Ophthalmics, Antibiotics
Ophthalmics, Antibiotic-Steroid Combinations
Ophthalmics, Anti-Inflammatories
Ophthalmics, Glaucoma
Opioid Overdose Agents
Opioid Use Disorder Treatments
Otic Antibiotic Preparations
Pancreatic Enzymes
Penicillins
Phosphate Binders
Pituitary Suppressive Agents, LHRH
Platelet Aggregation Inhibitors
Potassium Removing Agents
Prenatal Vitamins
Progestational Agents
Proton Pump Inhibitors (PPIs)
Pulmonary Hypertension Agents, Oral and Inhaled
Sedative Hypnotics
Sickle Cell Anemia Agents
Skeletal Muscle Relaxants
Smoking Cessation Products
Steroids, Topical
Stimulants and Related Agents
Tetracyclines
Thalidomide and Derivatives
Thrombopoietics
Thyroid Hormones
Tysabri (natalizumab)
Ulcerative Colitis Agents
Urea Cycle Disorder Agents
Urinary Anti-Infectives (formerly Nitrofuran Derivatives)
Vaginal Anti-Infectives (formerly Antibiotics, Vaginal)
Vitamin D Analogs
VMAT2 Inhibitors
Zeposia (ozanimod)
Abecma
Adstiladrin
Alpha-1 Proteinase Inhibitors (Aralast-NP, Glassia, Prolastin-C, Zemaira)
Amvuttra
Amyloid-Targeted Monoclonal Antibodies (MABs) (Aduhelm, Leqembi)
Anti-Allergens, Oral (Grastek, Odactra, Oralair, Ragwitek)
Benlysta
Breyanzi
Brineura
Camzyos
Carvykti
Clinical Prior Authorization of Non-PDL Drugs
Complement Inhibitors (Empaveli, Enjaymo, Soliris, Tavneos, Ultomiris)
Compounded Prescriptions
Corlanor
Corticotropin (formerly H.P. Acthar Gel)
Cough and Cold Medications
Crysvita
Cystic Fibrosis Transmembrane Regulator (CFTR) Modulators (Kalydeco, Orkambi, Symdeko, Trikafta)
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
Early Refills of Prescriptions
Elevidys
Elitek
Evrysdi
Filspari
Growth Factors
Imcivree
Immune Globulins
Joenja
Kanuma
Korlym
Kuvan/sapropterin
Kymriah
Mozobil
Nuedexta
Omisirge
Onpattro
Palforzia
Palynziq
Provenge
Quantity Limits/Daily Dose Limits
Radicava
Roctavian
Skyclarys
Skysona
Spinraza
Synagis
Tecartus
Tegsedi
Tepezza
Tzield
Vecamyl
Vuity
Vyjuvek
Vyndamax
Vyndaqel
Xermelo
Xofigo
Xyrem/Xywav
Yescarta
Zolgensma
Zynteglo