Statewide Preferred Drug List (PDL) Implementation
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Establishes implementation of a Statewide Preferred Drug List effective Jan 1, 2020, governing prior authorization and use of the PDL for Fee-For-Service and Medical Assistance managed care organizations in Pennsylvania.
No material clinical or coverage changes in this revision.
Coverage Criteria
This document does not set out individual drug-specific coverage criteria or exclusions. Coverage determinations for specific products are governed by the Statewide Preferred Drug List (PDL) and any prior authorization rules or exclusions referenced on the PDL and by MCO policies.
For drugs listed on the PDL, prior authorization is required and providers must follow the Department’s Fee‑For‑Service prior authorization procedures or the MCO‑specific prior authorization processes as applicable. The Statewide PDL and its prior authorization guidelines apply to both FFS and MA MCOs; consult www.papdl.com and the listed prior authorization resources for the definitive requirements.
Provider Actions and Requirements
Prior authorization required for PDL drugs
Prior authorization is required for drugs on the Statewide PDL; these same prior authorization guidelines will be utilized by Fee‑For‑Service (FFS) and Medical Assistance managed care organizations (MCOs).
Uniform PA and step‑therapy rules across FFS and MCOs
The Statewide PDL uses the same prior authorization guidelines — including any step therapy rules contained therein — across FFS and MA MCOs, so providers must follow the uniform clinical requirements published on the PDL.
Use DHS FFS PA procedures to request authorization
Providers must follow the Department's Fee‑For‑Service procedures for prescribers to request prior authorization and must contact MCOs for any MCO‑specific prior authorization procedures.
- FFS prescriber PA procedures: http://www.dhs.pa.gov/provider/pharmacyservices/pharmacypriorauthorizationgeneralrequirements/index.htm
- Contact the member's MCO for MCO‑specific prior authorization processes
PA required for PDL drugs — consequences for missing authorization
Drugs on the Statewide PDL are subject to prior authorization consistent with the PDL guidelines; failure to obtain required prior authorization may result in a temporary supply delay or claim denial/noncoverage per PDL/MCO rules.
- A temporary supply is available if a MA beneficiary's prescription is not filled due to a PA requirement
- Providers risk noncoverage or claim denial if required PA is not obtained
Definitions
Step Therapy Rules
| Policy | Application | Provider action |
|---|---|---|
| Step therapy rules contained in the Statewide Preferred Drug List (PDL) and its prior authorization guidelines | ||
| Applied to Fee‑For‑Service (FFS) and Medical Assistance managed care organizations (MCOs) in HealthChoices and Community HealthChoices | ||
| Consult the Statewide PDL (www.papdl.com) and follow FFS prior authorization procedures or contact the member's MCO for MCO‑specific step therapy/prior authorization requirements |
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