Hydroxychloroquine Quantity Limits - COVID-19
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Defines quantity limits and prior authorization rules for hydroxychloroquine prescriptions for Pennsylvania Medical Assistance programs (FFS and managed care) during the COVID-19 emergency period; affects prescribers, pharmacies, and MA beneficiaries.
No material clinical or coverage changes in this revision.
Coverage Criteria
Quantity limits and COVID-19 review
Covered when meeting program rules and authorization status:
Automated approvals at pharmacy point-of-sale will be issued for medically accepted non-COVID-19 diagnoses. Prior authorization overrides will be issued for current non-COVID-19 users to obtain their usual day supply.
No prior authorization approvals will be issued for COVID-19 prophylaxis. This applies to hydroxychloroquine requests submitted for prophylactic use during the COVID-19 emergency period and is consistent with the Medical Assistance Program guidance on quantity limits and prior authorization for COVID-19–related prescribing.
Coding and Thresholds
Provider Actions and Prior Authorization
Prior authorization required for excess quantity or duration
Prior authorization is required when hydroxychloroquine is prescribed at a quantity greater than 4 tablets per day or for a day supply greater than 10 days. Automated pharmacy point-of-sale approvals will be issued for medically accepted non-COVID-19 diagnoses, and prior authorization overrides will be issued for current non-COVID-19 users to obtain their usual day supply at the pharmacy.
- Quantity threshold: greater than 4 tablets/day
- Day supply threshold: greater than 10 days
- Automated POS approvals for medically accepted non-COVID-19 diagnoses
- Prior authorization overrides for current non-COVID-19 users
Exception — COVID-19 prophylaxis is not authorized
Urgent: No prior authorization approvals will be issued for COVID-19 prophylaxis; submit requests for COVID-19 treatment durations only when supported by medical necessity and current literature.
- Prophylaxis requests for COVID-19 will not be approved under any prior authorization.
- Treatment-duration requests must include justification based on current medical literature and specialist/prescriber input.
Documentation required for COVID-19 longer-duration requests
Prior authorization requests for longer durations to treat COVID-19 will be reviewed for medical necessity and approved based on current medical literature and specialist/prescriber input.
- Include clinical rationale and any specialist recommendations when requesting durations beyond the 10-day limit.
- Approvals are discretionary and based on evolving evidence.
Quantity/Duration triggers prior authorization and denial risk
Prescriptions that exceed 4 tablets per day or a day supply greater than 10 days will trigger prior authorization and may be denied if not approved.
- Pharmacies should expect POS adjudication to require authorization for these thresholds.
- Providers should submit prior authorization before dispensing to avoid denial or gaps in therapy.
Background
The U.S. Food and Drug Administration issued an Emergency Use Authorization on March 28, 2020 allowing hydroxychloroquine to be used to treat COVID-19. To prevent potential shortages and stockpiling and to protect supply for chronic users, the Medical Assistance Program implemented quantity and day-supply limits and related pharmacy point-of-sale safeguards. Automated POS approvals and prior-authorization overrides are provided for medically accepted non-COVID-19 diagnoses and current non-COVID-19 users so these patients can obtain their usual day supply, while requests for longer COVID-19 treatment durations will be reviewed for medical necessity using current literature and specialist input.
Definitions
Initial Therapy Criteria
Initial therapy limits
Continuation Criteria
Continuation for current users
Prior authorization overrides
Quantity Limits
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