Pennsylvania Insurance Department Prior Authorization Lookup
- Pennsylvania Insurance Department coverage criteria
- All Pennsylvania Insurance Department policy updates
Latest Pennsylvania Insurance Department prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-03-30Prior Authorization of Sickle Cell Anemia Agents - Pharmacy ServicesThis bulletin updates prior authorization requirements and medical necessity guidelines for sickle cell anemia agents for providers and pharmacies enrolled in Pennsylvania Medical Assistance; it applies to fee-for-service and managed care delivery systems and affects prescribers and licensed pharmacies serving MA beneficiaries.All Pennsylvania Insurance Department updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-12-30Family Planning Services Program — Covered Services ChartA covered-services chart listing procedure codes, billing modifiers, provider types/specialties, place of service, fees, prior authorization status, unit limits, post-op day rules, and billing comments for the Pennsylvania Family Planning Services Program.All Pennsylvania Insurance Department updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-08-01Medical Assistance Program Dental Fee Schedule (Dental services and rates)This document lists Pennsylvania Medical Assistance dental procedure codes (D and select CPT codes), provider types/places of service, fees, prior authorization flags, limits, and reporting requirements effective August 1, 2025; it affects providers billing Pennsylvania Medical Assistance for dental services.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2024-01-08Prior Authorization of Pituitary Suppressive Agents, LHRH - Pharmacy ServicesDefines prior authorization requirements and medical necessity criteria for pituitary suppressive agents (LHRH) for all licensed pharmacies and prescribers enrolled in Pennsylvania Medical Assistance, including FFS and MA MCOs.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2022-09-01Prior Authorization of Antipsoriatics, Oral - Pharmacy ServicesDefines 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).All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2022-09-01Prior Authorization of Thyroid Hormones - Pharmacy ServicesThis 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.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2021-01-05Prior Authorization of Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides - Pharmacy ServicesThis bulletin requires prior authorization for prescriptions of DMD antisense oligonucleotides for Pennsylvania Medical Assistance fee-for-service beneficiaries and provides the clinical documentation and review requirements for prescribers and pharmacies.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-04-01DexCom Continuous Glucose Monitoring (CGM) products — Coverage and BillingDefines coverage and billing rules for DexCom CGM products for Pennsylvania Medicaid Fee-for-Service beneficiaries, including benefit routing (DME vs pharmacy), prior authorization, and quantity limits.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-03-28Hydroxychloroquine Quantity Limits - COVID-19Defines quantity limits and prior authorization rules for hydroxychloroquine prescriptions for Pennsylvania Medical Assistance programs (FFS and managed care) during the COVID-19 emergency period; affects prescribers, pharmacies, and MA beneficiaries.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Anti-Allergens, Oral - Pharmacy ServicesGoverns prior authorization requirements and medical necessity criteria for oral anti-allergen prescriptions for providers and pharmacies participating in Pennsylvania Medical Assistance fee-for-service.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Antifungals, Oral - Pharmacy ServicesThis bulletin updates handbook pages and medical necessity guidelines governing prior authorization requirements for oral antifungal prescriptions for providers in the Pennsylvania Medical Assistance fee-for-service system.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Antivirals, Herpes - Pharmacy ServicesGoverns prior authorization requirements and medical necessity review criteria for Antivirals, Herpes for providers and pharmacies in Pennsylvania's Medical Assistance fee-for-service program.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Fluoroquinolones, Oral - Pharmacy ServicesUpdates 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.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Histamine 2 (H2) Receptor Blockers - Pharmacy ServicesThis bulletin establishes prior authorization requirements and medical necessity review guidelines for prescriptions of Histamine 2 (H2) Receptor Blockers for providers in Pennsylvania's Medical Assistance fee-for-service program.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Iron, Parenteral - Pharmacy ServicesEstablishes prior authorization requirements and medical necessity review criteria for parenteral iron prescriptions for providers enrolled in Pennsylvania Medical Assistance fee-for-service.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Ophthalmics, Antibiotic-Steroid CombinationsGoverns prior authorization requirements and medical necessity review for non-preferred ophthalmic antibiotic-steroid combination prescriptions for providers and pharmacies in Pennsylvania's Medical Assistance fee-for-service program.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Steroids, TopicalThis 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.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Prior Authorization — Ophthalmics, Allergic ConjunctivitisRules for prior authorization of non-preferred ophthalmic products for allergic conjunctivitis for providers and pharmacies enrolled in Pennsylvania Medical Assistance fee-for-service; managed care providers should consult their MCO.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2020-01-01Statewide Preferred Drug List (PDL) ImplementationEstablishes 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.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2019-07-08Prior Authorization of Antibiotics, Inhaled - Pharmacy ServicesRequirements and clinical review guidelines for prior authorization of inhaled antibiotic prescriptions for providers in the Pennsylvania Medical Assistance fee-for-service program.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2019-01-28Prior Authorization of Alpha-1 Proteinase InhibitorsGoverns prior authorization requirements and medical necessity criteria for prescriptions of Alpha-1 Proteinase Inhibitors for Medical Assistance (fee-for-service) providers and pharmacies in Pennsylvania's MA program.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2019-01-22Prior Authorization of Radicava (edaravone) - Pharmacy ServicesThis bulletin establishes prior authorization requirements and clinical review criteria for prescriptions of Radicava (edaravone) for Pennsylvania Medical Assistance fee-for-service providers and enrolled pharmacies; managed care providers should contact their MCOs.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyEff. 2016-06-13Prior Authorization of Provenge (sipuleucel-T) - Pharmacy ServiceRequires prior authorization for all Provenge (sipuleucel-T) prescriptions under Pennsylvania Medical Assistance fee-for-service and describes the clinical documentation and dose/duration limits used to determine medical necessity for covered recipients.All Pennsylvania Insurance Department updates
- Prior AuthReimbursement/Payment PolicyEff. 2012-06-01Home and Community Based Waiver Services — Attachment A (Fee Schedule)Lists rates and billing units for Home and Community Based Waiver Services (Attachment A), providing per-service rates, unit definitions, regional columns, and applicability flags; no explicit coverage or prior-authorization rules are included in this attachment.All Pennsylvania Insurance Department updates
- Prior AuthClinical/Medical PolicyPrior Authorization Requirements for Immune GlobulinsGoverns prior authorization (PA) requirements and medical necessity review criteria for all prescriptions of immune globulins for Pennsylvania Medical Assistance recipients.All Pennsylvania Insurance Department updates
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Tool Description
Search Pennsylvania Insurance Departmentprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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