Prior Authorization of Thyroid Hormones - Pharmacy Services
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This bulletin updates Medical Assistance prior authorization requirements and medical necessity guidelines for thyroid hormone prescriptions for all licensed pharmacies and prescribers enrolled in the Pennsylvania MA Program; it applies to fee-for-service and MA MCOs in Physical Health HealthChoices and Community HealthChoices.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial prior authorization criteria
Covered when ALL of the following are met
If met, reviewer will prior authorize; if not met, refer to physician reviewer.
Reviewer applies Quantity Limits Chapter; may be approved if physician reviewer determines medically necessary.
This bulletin establishes the clinical review guidelines used to determine medical necessity for prior authorization of Thyroid Hormone prescriptions. Coverage is determined by applying the criteria in Section B (Review of Documentation for Medical Necessity). For non-preferred Thyroid Hormones, the reviewer will require documentation of a history of therapeutic failure of, or a contraindication or intolerance to, preferred Thyroid Hormones. When a prescription exceeds the established quantity limit, medical necessity will be assessed using the Department’s Quantity Limits Chapter guidelines.
Prior authorization personnel will apply the clinical review guidelines to each request. If the guidelines are not satisfied, the 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 to meet the beneficiary’s needs; otherwise the request may be denied.
Initial Therapy Criteria
Non-preferred thyroid hormone initial therapy
Initial coverage requirement for non-preferred agents
Required for prior authorization of non-preferred Thyroid Hormones; if not documented, request will be referred to a physician reviewer for medical necessity determination.
Provider Actions & Documentation Requirements
Prior authorization required for non-preferred agents and quantity-limit exceedances
Prior authorization is required for prescriptions that are for a non-preferred thyroid hormone and for prescriptions with a quantity that exceeds the Department's established quantity limits.
- Non-preferred agents are identified on the Preferred Drug List (PDL).
- Quantity limits are listed on the Department's Quantity Limits and Daily Dose Limits page.
Document therapeutic failure, contraindication, or intolerance of preferred products
For a non-preferred thyroid hormone, the request must include documentation showing the beneficiary has a history of therapeutic failure of, a contraindication to, or an intolerance of the preferred thyroid hormones.
- Meeting this requirement is necessary for prior authorization of non-preferred thyroid hormones.
- If not met, the request will be referred to a physician reviewer (see denial risk).
Use SECTION I procedures and SECTION II clinical guidelines in the Prior Authorization Handbook
Follow the procedures in SECTION I of the Prior Authorization of Pharmaceutical Services Handbook when submitting prior authorization requests; reviewers will consider the clinical review elements in SECTION II when assessing medical necessity.
- SECTION I contains the procedural requirements for prescribers to request prior authorization.
- SECTION II includes the clinical review guidelines and the Quantity Limits Chapter referenced for quantity exceedance evaluations.
Risk of denial if clinical guidelines are not met
Requests that do not meet the clinical review guidelines will be referred to a physician reviewer and may be denied unless the physician reviewer determines the service is medically necessary.
- If Section B guidelines are met, the prior authorization reviewer will approve the prescription; if not, referral to a physician reviewer occurs.
- A physician reviewer may approve the request based on professional judgment when medically necessary; otherwise the request may be denied.
Coding and Limits
Quantity Limits (Drugs)
Definitions
Background
This bulletin updates the medical necessity guidelines for Thyroid Hormones to clarify and align review language; no other substantive changes were made. The guidance specifies the documentation reviewers will consider for non-preferred Thyroid Hormones and for prescriptions that exceed quantity limits, and affirms that physician reviewers may approve requests judged medically necessary.
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