Prior Authorization of Steroids, Topical
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This bulletin governs prior authorization requirements and medical necessity review criteria for non-preferred topical steroids for providers (pharmacies and prescribers) in Pennsylvania's Medical Assistance fee-for-service program.
The Department combined separate medical necessity guidelines for low, medium, high, and very high potency topical steroids into a single guideline titled 'Steroids, Topical'.
Medical necessity review of non-preferred topical steroids will take into account the potency of the requested steroid and the beneficiary's diagnosis.
Coverage Criteria
Medical necessity criteria for prior authorization
Covered when ALL of the following are met
See SECTION I for submission process; non-preferred list on PDL.
If clinical guidelines not met, the request will be referred to a physician reviewer for medical necessity determination.
Preferred topical steroids listed on the Preferred Drug List (PDL) are not subject to this prior authorization requirement. Prescriptions for non-preferred topical steroids must be prior authorized; see the PDL for the list of preferred Steroids, Topical.
Requests that do not meet the clinical review guidelines in Section B will be referred to a physician reviewer and may be denied unless the physician reviewer, in professional judgment, determines that the requested services are medically necessary for the beneficiary.
Actions for Providers
Prior authorization required for non-preferred topical steroids
Prescriptions for non-preferred topical steroids require prior authorization; prescribers must submit requests according to the handbook procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook.
- Non-preferred agents are those not listed on the Preferred Drug List (PDL).
- See the PDL at https://papdl.com/preferred-drug-list for preferred Steroids, Topical.
Therapeutic failure / intolerance must be documented
The clinical review will consider whether the beneficiary has a documented history of therapeutic failure, contraindication, or intolerance to preferred topical steroids of the same relative potency (low, medium, high, very high) approved or medically accepted for the beneficiary's diagnosis.
- History of therapeutic failure, contraindication, or intolerance must be to preferred agents of the same relative potency.
- If the clinical review guidelines are not met, the physician reviewer may still approve based on professional judgment.
Follow SECTION I handbook procedures to submit requests
Providers must follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook when submitting prior authorization requests and include the elements specified in the clinical review guidelines in SECTION II related to Steroids, Topical.
- Handbook procedures are required by 55 Pa. Code § 1101.67(a) to ensure appropriate and timely processing.
- Include documentation elements listed in SECTION II (Steroids, Topical) to support medical necessity.
Requests not meeting clinical guidelines may be denied
If the request does not meet the clinical guidelines in Section B, prior authorization personnel will refer the request to a physician reviewer and the request may be denied unless the physician reviewer determines the services are medically necessary.
- Requests not meeting Section B are escalated to a physician reviewer for a medical necessity determination.
- Approval may still be granted only if the physician reviewer, in professional judgment, finds the services medically necessary.
Background
Topical corticosteroids are grouped by relative potency (low, medium, high, very high). The Department consolidated separate potency-specific guidelines into a single Steroids, Topical guideline so that medical necessity review of non-preferred agents will consider the potency of the requested steroid and the beneficiary's diagnosis.
Definitions
Initial Therapy Criteria
Initial therapy
Initial authorization considerations
PDL lists preferred agents; handbook SECTION II contains clinical review guidelines.
Step Therapy / Documentation Requirements
| Step | Requirement | Notes |
|---|---|---|
| 1 | Must document history of therapeutic failure, contraindication, or intolerance to preferred topical steroids of the same relative potency | Relative potency = low, medium, high, very high; documentation supports prior authorization request and may be overridden by physician reviewer on professional judgment |
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