Prior Authorization of Antivirals, Herpes - Pharmacy Services
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Governs prior authorization requirements and medical necessity review criteria for Antivirals, Herpes for providers and pharmacies in Pennsylvania's Medical Assistance fee-for-service program.
The Antivirals, Herpes drug class was added to the Preferred Drug List (PDL).
Handbook pages specifying prior authorization procedures and clinical review guidelines for Antivirals, Herpes were issued/updated.
Coverage and Medical Necessity Criteria
Medical necessity criteria (non-preferred agents and quantity-limit exceedances)
Covered when ALL of the following are met:
If the guidelines in Section B are not met, the request will be referred to a physician reviewer; the physician reviewer may approve the request based on professional judgment.
Prescriptions for Antivirals, Herpes that require prior authorization include: 1) any non-preferred Antiviral, Herpes (check the Preferred Drug List (PDL) for the current preferred agents); and 2) any Antiviral, Herpes prescribed in a quantity that exceeds the Department's Quantity Limits. Consult the PDL at the Department's PDL website and the Department Quantity Limits list for drug-specific limits and numeric thresholds.
Requests for non-preferred agents must include documentation demonstrating a history of therapeutic failure, intolerance, or contraindication to preferred Antivirals, Herpes for the beneficiary's diagnosis or indication; when the requested quantity exceeds published limits, the request must also meet the Quantity Limits chapter guidelines. Prior authorization personnel will apply these clinical guidelines during review.
If the clinical guidelines are not met during initial review, the request will be referred to a physician reviewer. The physician reviewer may approve the request when, in their professional judgment, the services are medically necessary despite not meeting the standard clinical criteria.
Coding and Billing
| No codes listed |
Prior Authorization, Documentation, and Provider Responsibilities
Prior authorization required for non-preferred agents and quantity-limit exceedances
Prior authorization must be obtained when the prescription is for a non-preferred Antiviral, Herpes or when the prescribed quantity exceeds the Department's quantity limit; follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook when requesting prior authorization.
- Follow SECTION I procedures in the Prior Authorization of Pharmaceutical Services Handbook for submission and processing.
- Non-preferred agents are identified on the Preferred Drug List (PDL).
- Quantity-limit exceedances refer to the Department Quantity Limits list.
Step therapy requirement — document prior failure/intolerance/contraindication
Medical necessity for coverage of a non-preferred Antiviral, Herpes requires documentation that the beneficiary has a history of therapeutic failure, intolerance, or contraindication to preferred Antivirals, Herpes approved for the beneficiary's diagnosis or indication.
- Step therapy (failure/intolerance/contraindication to preferred agents) must be documented to approve a non-preferred agent.
- If quantity limits are also exceeded, quantity-limit guidelines apply in addition to step therapy requirements.
Required clinical documentation for non-preferred agents and quantity-limit exceedances
When requesting prior authorization for a non-preferred Antiviral, Herpes or for a prescription that exceeds quantity limits, providers must submit clinical documentation showing the beneficiary's history of therapeutic failure, intolerance, or contraindication to preferred Antivirals, Herpes; for quantity-limit requests, also follow the Quantity Limits chapter guidelines.
- Include records that demonstrate prior therapeutic failure, documented intolerance, or a contraindication to preferred agents for the beneficiary's diagnosis or indication.
- For quantity-limit overrides, supply the clinical rationale aligned with the Quantity Limits chapter.
Denial risk for insufficient documentation
Requests for non-preferred antivirals or prescriptions exceeding quantity limits that do not include the required documentation (history of therapeutic failure, intolerance, or contraindication to preferred agents, or appropriate quantity-limit justification) may be denied or referred to a physician reviewer for medical necessity determination.
- If clinical guidelines in Section B are not met, the request will be referred to a physician reviewer and may be denied if medical necessity is not established.
- Insufficient documentation for quantity-limit exceedances may result in denial unless Quantity Limits chapter guidelines are satisfied.
Policy Background
The Department's Pharmacy & Therapeutics Committee reviews the literature and provides recommendations on PDL status and clinical prior authorization guidelines. The Antivirals, Herpes class was reviewed and added to the PDL with accompanying clinical guidelines used by prior authorization personnel and physician reviewers to assess medical necessity.
Key Definitions
Initial Authorization Criteria
Initial therapy criteria
Initial authorization for non-preferred agents:
Quantity limits are evaluated separately per the Quantity Limits chapter; prior authorization procedures in SECTION I of the Prior Authorization Handbook must be followed.
Step Therapy Documentation
| Requirement | Details |
|---|---|
| Documentation of prior therapeutic failure, intolerance, or contraindication to preferred Antivirals, Herpes | For a non-preferred Antiviral, Herpes, the beneficiary must have a documented history of therapeutic failure, intolerance, or contraindication to preferred Antivirals, Herpes approved for the beneficiary's diagnosis or indication. |
| Quantity-limit exceedance review | If the requested quantity exceeds the Department's quantity limits, medical necessity will also be evaluated using the Quantity Limits chapter guidelines. |
| Physician reviewer discretion | If the beneficiary does not meet the clinical review guidelines but the physician reviewer determines the service is medically necessary based on professional judgment, prior authorization may be approved. |
Quantity Limits and Overrides
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