Prior Authorization of Antifungals, Oral - Pharmacy Services
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This bulletin updates handbook pages and medical necessity guidelines governing prior authorization requirements for oral antifungal prescriptions for providers in the Pennsylvania Medical Assistance fee-for-service system.
Medical necessity guidelines for non-preferred oral antifungals were updated to require consideration of culture and sensitivity results and the beneficiary's diagnosis.
Guidance was added to allow determination of medical necessity for prescriptions exceeding established quantity limits.
Coverage Criteria for Oral Antifungals
Initial coverage for non-preferred oral antifungals
Covered when ALL of the following are met
Reviewer must verify documented evidence; if not met, refer to physician reviewer.
Coverage when requested quantity exceeds limit
When quantity exceeds limit
May require additional documentation per Quantity Limits guidance.
Preferred agents listed on the Pennsylvania Preferred Drug List (PDL) are exempt from the prior authorization requirements that apply to non-preferred oral antifungals. In other words, a product that appears as a preferred Antifungal, Oral on the PDL does not require prior authorization under the non-preferred agent criteria; only a non-preferred Antifungal, Oral or a prescription with a quantity exceeding established limits must follow the prior authorization procedures.
If the clinical review guidelines in Section B are not met, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. The physician reviewer may approve the request when, in their professional judgment, the service is medically necessary; otherwise the request may be denied.
Coding and Quantity Limits
| See PDL | Preferred Drug List identifies preferred oral antifungals |
| See quantity limits list | Drugs subject to quantity limits and their limits are listed at the Department quantity limits page |
Provider Actions, Prior Authorization & Documentation
Prior authorization required for non-preferred agents and quantities exceeding limits
Prescriptions for oral antifungals that are non-preferred on the Pennsylvania Preferred Drug List or that specify a quantity exceeding the Department’s established quantity limits must be submitted with a prior authorization following the SECTION I procedures in the Prior Authorization of Pharmaceutical Services Handbook.
- Non-preferred agents: see the Preferred Drug List at https://papdl.com/preferred-drug-list (PDL).
- Quantity limits: see the Department quantity limits page for drugs and exact thresholds.
Therapeutic failure (or equivalent) required for non-preferred coverage
Prior authorization requests for a non-preferred oral antifungal must include evidence that the beneficiary has had therapeutic failure, a contraindication, or intolerance to preferred oral antifungals approved or medically accepted for the beneficiary’s diagnosis, or culture and sensitivity results documenting that only a non-preferred agent will be effective.
- Therapeutic failure, contraindication, or intolerance to preferred agents OR
- Culture and sensitivity test results showing only a non-preferred agent will be effective
Required documentation for prior authorization
Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook and submit documentation to demonstrate medical necessity, including evidence of therapeutic failure/contraindication/intolerance to preferred agents or culture and sensitivity results when requesting a non-preferred oral antifungal.
- Use SECTION I handbook procedures to request prior authorization.
- Include supporting clinical documentation as described in Section B (therapeutic failure, contraindication, intolerance, or culture/sensitivity).
- If quantity exceeds limits, include any additional documentation required by the Quantity Limits Chapter.
Denial risk if clinical guidelines not met
If the prior authorization request does not meet the clinical guidelines in Section B, it will be referred to a physician reviewer and may be denied unless the physician reviewer determines the service is medically necessary.
- Failure to meet Section B clinical review guidelines (therapeutic failure/contraindication/intolerance or culture/sensitivity criteria, and Quantity Limits guidance when applicable) risks denial.
- Requests referred to a physician reviewer will be approved only if, in that reviewer’s professional judgment, the services are medically necessary.
Background
This bulletin updates the medical necessity review for oral antifungals to require incorporation of relevant diagnostic information during prior authorization. Reviewers will apply the Section B clinical guidelines and consider the beneficiary’s diagnosis and available laboratory data — including culture and sensitivity results — when determining whether a non-preferred oral antifungal is medically necessary. When requested quantities exceed established limits, reviewers will also apply the Department’s Quantity Limits guidance as part of the medical necessity assessment.
Definitions
Initial Therapy Criteria
Initial therapy criteria
Initial coverage determinations for non-preferred oral antifungals
If guidelines are not met, request will be referred to a physician reviewer who may approve if, in their professional judgment, the service is medically necessary.
Step Therapy Requirements
| Requirement | Details |
|---|---|
| Documentation of therapeutic failure, contraindication, or intolerance to preferred oral antifungals | Provider must document history that the beneficiary experienced therapeutic failure, a contraindication, or intolerance to preferred Antifungals, Oral approved or medically accepted for the beneficiary's diagnosis. |
| Culture and sensitivity results (alternative to therapeutic failure) | Submit culture and sensitivity test results demonstrating that only a non-preferred Antifungal, Oral will be effective for the beneficiary. |
| Quantity-exceeding prescriptions | If the requested quantity exceeds established quantity limits, medical necessity determination will also consider the guidelines in the Quantity Limits Chapter and may require additional documentation. |
| Physician reviewer discretion | If clinical review guidelines are not met, a physician reviewer may still approve the request if, in their professional judgment, the service is medically necessary. |
Quantity Limits
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