Prior Authorization of Ophthalmics, Antibiotic-Steroid Combinations
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Governs prior authorization requirements and medical necessity review for non-preferred ophthalmic antibiotic-steroid combination prescriptions for providers and pharmacies in Pennsylvania's Medical Assistance fee-for-service program.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial prior authorization criteria
Covered when ALL of the following are met
If the beneficiary does not meet these clinical review guidelines but the physician reviewer determines the service is medically necessary, the prior authorization will be approved.
Preferred products listed on the state Preferred Drug List (PDL) do not require prior authorization. Only prescriptions for non-preferred Ophthalmic, Antibiotic-Steroid Combination products must be submitted for prior authorization; see the PDL at https://papdl.com/preferred-drug-list for the list of preferred preparations.
If a prior authorization request does not meet the clinical review guidelines (history of therapeutic failure, contraindication, or intolerance to preferred products), the request will be referred to a physician reviewer. Requests that still are not supported by the physician reviewer’s professional judgment will be denied as not medically necessary.
Provider Actions & Requirements
Prior authorization required for non‑preferred products
Prior authorization is required for any prescription of a non-preferred ophthalmic antibiotic‑steroid combination; the reviewer will approve the request only if the clinical criteria are met (history of therapeutic failure, contraindication, or intolerance to preferred agents).
Step requirement: prior failure/intolerance to preferred agents
Medical necessity for coverage of a non‑preferred product requires evidence that the beneficiary has experienced prior therapeutic failure, a contraindication, or intolerance to preferred Ophthalmic Antibiotic‑Steroid Combinations — i.e., a step from preferred agents is expected before non‑preferred coverage.
- Determination of medical necessity “will take into account the whether the beneficiary: 1. Has a history of therapeutic failure, contraindication, or intolerance to the preferred Ophthalmics, Antibiotic‑Steroid Combinations.”
Documentation required to support prior authorization
Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook and supply documentation that addresses the clinical review guidelines (history of therapeutic failure, contraindication, or intolerance to preferred products) as described in SECTION II.
- Submit documentation per SECTION I of the Prior Authorization handbook.
- Include clinical evidence addressing the Section II review criteria (history of therapeutic failure, contraindication, or intolerance).
Denial triggers when clinical guidelines are not met
If the clinical review guidelines (history of therapeutic failure, contraindication, or intolerance to preferred products) are not met, the request will be referred to a physician reviewer and may be denied if the physician reviewer does not find the service medically necessary.
- Requests failing to meet Section B clinical guidelines are referred to a physician reviewer for a medical necessity determination.
- Requests not supported by the physician reviewer’s professional judgment will be denied as not medically necessary.
Initial Therapy Prior Authorization
Initial therapy prior authorization
Prior authorization required for non-preferred products; medical necessity review considers prior failure or intolerance to preferred products.
Prior authorization personnel will apply these clinical guidelines; if guidelines are not met the request is referred to a physician reviewer who may approve if, in their professional judgment, the service is medically necessary.
Step Therapy
| Step | Requirement |
|---|---|
| 1 | |
| Document prior failure, contraindication, or intolerance to preferred Ophthalmic, Antibiotic-Steroid Combinations (PDL-listed agents) before a non-preferred product will be approved. |
Definitions
Background
This bulletin updates the prior authorization procedures and renames the drug class to "Ophthalmics, Antibiotic-Steroid Combinations." It establishes that prescriptions for non-preferred products in this class require prior authorization and that medical necessity for such requests will be determined by documentation of a beneficiary’s history of therapeutic failure, contraindication, or intolerance to preferred agents listed on the PDL. The bulletin also notes that, when criteria are not met, a physician reviewer may still approve the request if, in the reviewer’s professional judgment, the services are medically necessary.
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