Prior Authorization of Histamine 2 (H2) Receptor Blockers - Pharmacy Services
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This bulletin establishes prior authorization requirements and medical necessity review guidelines for prescriptions of Histamine 2 (H2) Receptor Blockers for providers in Pennsylvania's Medical Assistance fee-for-service program.
No material clinical or coverage changes in this revision.
Coverage Criteria for H2 Receptor Blockers
Medical necessity criteria for H2 receptor blockers
Covered when ALL of the following are met
If the beneficiary does not meet these clinical review guidelines, the request will be referred to a physician reviewer and may be approved only if the physician reviewer determines the service is medically necessary.
Prescriptions exceeding listed quantity limits require prior authorization and review under Quantity Limits Chapter.
This bulletin applies to providers enrolled in Pennsylvania's Medical Assistance (MA) Program who deliver services in the fee-for-service delivery system. Providers rendering services in the MA managed care delivery system should contact their managed care organization (MCO) for questions or prior authorization requirements for H2 receptor blockers, as this bulletin covers fee-for-service only.
Prior authorization personnel will apply the clinical guidelines in Section B when reviewing requests. Requests that do not meet those clinical review guidelines will be referred to a physician reviewer for a medical necessity determination; the physician reviewer may approve the request if, in their professional judgment, the services are medically necessary for the beneficiary.
Coding and Quantity Limit References
Provider Actions and Prior Authorization Requirements
Prior authorization required for non-preferred agents and quantity-exceeding prescriptions
Prior authorization is required for any non-preferred H2 receptor blocker and for H2 receptor blocker prescriptions that exceed published quantity limits. See the Department Preferred Drug List for preferred agents and the Department quantity limits list for exact limits.
- Non-preferred agents: refer to PDL at https://papdl.com/preferred-drug-list
- Quantity limits: refer to Department quantity limits list
Document failure, intolerance, or contraindication to preferred H2 agents
For approval of a non-preferred H2 receptor blocker, documentation must demonstrate a history of therapeutic failure, contraindication, or intolerance to the preferred H2 receptor blockers.
- Provider must document therapeutic failure, intolerance, or contraindication to preferred H2 receptor blockers before a non-preferred agent is authorized
Submit requests per Handbook SECTION I and include required clinical documentation
Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook when requesting prior authorization and supply documentation demonstrating the beneficiary's history of therapeutic failure, contraindication, or intolerance to preferred H2 receptor blockers; quantity-exceeding requests must follow Quantity Limits Chapter guidelines.
- Use SECTION I procedures in the Prior Authorization of Pharmaceutical Services Handbook for submitting requests
- Include documentation of failure/contraindication/intolerance for non-preferred agent requests
- If exceeding quantity limits, follow Quantity Limits Chapter guidance
Requests that fail to meet clinical review guidelines may be denied
Requests for non-preferred H2 receptor blockers or prescriptions exceeding published quantity limits that do not meet the clinical review guidelines may be denied; such requests will be referred to a physician reviewer and may be approved only if the reviewer determines they are medically necessary.
- Requests lacking documented failure/contraindication/intolerance to preferred agents risk denial
- Quantity-exceeding requests that do not meet Quantity Limits Chapter criteria risk denial
- Physician reviewer may approve only based on professional judgment of medical necessity
Background
The Department has updated the format of the medical necessity guidelines for H2 receptor blockers; there are no substantive clinical changes to the guidelines. Prior authorization reviews continue to follow the clinical review process described in the bulletin, with prior authorization personnel applying Section B clinical guidelines and referring unresolved cases to a physician reviewer.
Definitions
Initial Therapy Criteria
Initial therapy requirements
Initial coverage consideration for non-preferred agents
A physician reviewer may approve the request despite absence of documented failure/intolerance/contraindication if, in professional judgment, the service is medically necessary.
Step Therapy and Failure Documentation
| Requirement | Detail |
|---|---|
| Documentation of therapeutic failure, contraindication, or intolerance to preferred H2 receptor blockers | |
| Required for authorization of a non-preferred H2 receptor blocker; reviewer may approve without this if physician determines medically necessary |
Quantity Limits
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