Prior Authorization of Antipsoriatics, Oral - Pharmacy Services
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Defines prior authorization requirements and medical necessity review criteria for oral antipsoriatic prescriptions for providers and pharmacies enrolled in Pennsylvania Medical Assistance (fee-for-service and MA MCOs).
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity criteria
Covered when ALL of the following are met
NOTE: A physician reviewer may approve a request that does not meet the listed criteria when, in the reviewer’s professional judgment, the services are medically necessary.
None specified beyond non-preferred status and quantity-limit criteria. Specific drug exclusions, if any, are shown on the Department’s Preferred Drug List or on the Department Quantity Limits pages. See the Department PDL for the list of preferred oral antipsoriatics and the Department Quantity Limits page for drugs subject to limits.
Requests that lack documentation demonstrating a history of therapeutic failure of, or a contraindication or intolerance to, preferred oral antipsoriatics will not meet medical necessity criteria for non-preferred agents. Similarly, requests for quantities that exceed posted quantity limits must include justification consistent with the Quantity Limits Chapter; absent this documentation, the request will not meet medical necessity criteria unless a physician reviewer uses professional judgment to approve.
Quantity Limits and Coding Notes
Prior Authorization and Documentation Requirements
Prior authorization required for non‑preferred agents and quantity‑limit exceedances
Prior authorization is required when a prescription is for a non‑preferred oral antipsoriatic or when the prescribed quantity exceeds the Department’s posted quantity limits.
- Non‑preferred agents: see Preferred Drug List at https://papdl.com/preferred-drug-list.
- Quantity limits: see Department quantity limits page at https://www.dhs.pa.gov/providers/Pharmacy-Services/Pages/Quantity-Limits-and-Daily-Dose-Limits.aspx.
Therapeutic failure or contraindication/intolerance required
Authorization of non‑preferred oral antipsoriatics generally requires documentation that the beneficiary has had therapeutic failure of, or a contraindication or intolerance to, preferred oral antipsoriatics.
- Medical necessity for non‑preferred agents is based on history of therapeutic failure, or documented contraindication or intolerance to preferred agents.
Follow SECTION I procedures and include clinical documentation
Submit prior authorization requests following SECTION I of the Prior Authorization Handbook and include clinical documentation demonstrating history of therapeutic failure, contraindication, or intolerance to preferred oral antipsoriatics when requesting non‑preferred agents.
- Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook per 55 Pa. Code § 1101.67(a).
- Include clinical evidence of prior treatment failure, documented contraindication, or intolerance in the request.
Missing required documentation or exceeding limits may result in denial
Requests for non‑preferred oral antipsoriatics or for quantities above posted limits will be subject to prior authorization and may be denied if required medical necessity documentation (history of therapeutic failure, contraindication, or intolerance to preferred agents, or justification for quantity) is not provided.
- Absence of documentation of failure/contraindication/intolerance may render the request not medically necessary.
- Prescriptions exceeding quantity limits must meet Quantity Limits Chapter guidelines or may be denied.
Key Definitions
Step Therapy / Failure Documentation
| Step | Requirement |
|---|---|
| 1 | Documentation of prior therapeutic failure of preferred oral antipsoriatics, OR documentation of a contraindication or intolerance to preferred oral antipsoriatics is required to authorize a non-preferred oral antipsoriatic. |
Policy Background
This bulletin updates the Prior Authorization Handbook pages to clarify prior authorization and medical necessity review for oral antipsoriatic medications used in the Medical Assistance program (fee‑for‑service and MA MCOs). It explains that prior authorization is required for any non‑preferred oral antipsoriatic and for prescriptions with quantities that exceed posted quantity limits, and it describes the documentation and clinical review standards applied during authorization decisions.
Department Quantity Limits
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