Prior Authorization of Fluoroquinolones, Oral - Pharmacy Services
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Updates prior authorization requirements and medical necessity review criteria for non‑preferred oral fluoroquinolone prescriptions for providers and pharmacies in the Pennsylvania MA fee‑for‑service system.
Medical necessity guidelines for review of non‑preferred oral fluoroquinolones were updated to clarify that review will take into account the beneficiary's diagnosis.
Coverage Criteria
Initial Prior Authorization Criteria
Covered when ONE of the following is met:
If the beneficiary does not meet the clinical review guidelines but, in the professional judgement of the physician reviewer, the services are medically necessary, the request may be approved.
Prescriptions for non-preferred Fluoroquinolone, Oral agents require prior authorization. Consult the Pennsylvania Preferred Drug List (PDL) to identify agents listed as preferred; agents on the PDL do not require prior authorization.
Prior authorization personnel will apply the clinical guidelines in Section B when reviewing requests. If the request does not meet those guidelines, it will be referred to a physician reviewer and may be considered not medically necessary unless the physician reviewer, using professional judgment, approves the request as medically necessary.
Provider Actions & Requirements
Non‑preferred oral fluoroquinolones require prior authorization
Prescriptions for non-preferred oral fluoroquinolones must be prior authorized. Consult the Pennsylvania Preferred Drug List (PDL) to determine which fluoroquinolones are preferred and therefore do not require prior authorization.
- See the Preferred Drug List (PDL) at https://papdl.com/preferred-drug-list for the list of preferred Fluoroquinolones, Oral.
Clinical step requirement: attempt preferred agents or document microbiology
Approval requires documentation of one of the following clinical steps: (a) history of therapeutic failure, intolerance, or contraindication to preferred oral fluoroquinolones appropriate for the beneficiary's diagnosis; or (b) culture and sensitivity results showing only non‑preferred oral fluoroquinolones will be effective.
- History of therapeutic failure, intolerance, or contraindication to preferred Fluoroquinolones, Oral approved or medically accepted for the beneficiary's diagnosis.
- Culture and sensitivity test results documenting that only non‑preferred Fluoroquinolones, Oral will be effective.
Required documentation and procedure: use Handbook SECTION I and clinical elements in SECTION II
Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook when requesting prior authorization, and submit the clinical elements specified in the Section II guidelines for Fluoroquinolones, Oral to support medical necessity.
- The Department will take into account the elements specified in the clinical review guidelines included in the provider handbook pages (SECTION II) related to Fluoroquinolones, Oral.
- Per 55 Pa. Code § 1101.67(a), the handbook procedures must be followed to ensure appropriate and timely processing of prior authorization requests.
Denial risk when Section B guidelines are not met — physician review and possible denial
If the clinical guidelines in Section B are not met, the prior authorization request will be referred to a physician reviewer and may be denied if the physician reviewer does not find the drug medically necessary.
- Prior authorization personnel apply the Section B clinical guidelines to assess medical necessity; unmet guidelines trigger physician review.
- A request may be approved only when, in the professional judgment of the physician reviewer, the services are medically necessary to meet the beneficiary's needs.
Initial Therapy Requirements
Initial Therapy Requirements
Initial authorization requires documentation of one of the following:
Step Therapy
| Step | Requirement |
|---|---|
| 1 | Must try preferred oral fluoroquinolones appropriate for the beneficiary's diagnosis (history of therapeutic failure, intolerance, or contraindication to preferred agents), unless culture and sensitivity testing documents that only non‑preferred oral fluoroquinolones will be effective. |
Definitions
Background
The Department revised the medical necessity guidelines for non‑preferred oral fluoroquinolones to clarify that review will take into account the beneficiary's diagnosis. These revisions were subject to public comment and implemented via updated handbook pages; there are no other changes to the medical necessity guidelines.
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