Pennsylvania’s Medicaid Program Updates Prior Authorization Process for Opioid Prescribing

Effective June 6, 2017, Pennsylvania's Medicaid Program – known as Medical Assistance (MA) – updated its prior authorization process for opioid prescribing. The maximum number of 5-day supplies for a long-acting or short-acting opioid that can be dispensed without prior authorization is one (1) 5-day supply per MA beneficiary during a six (6) month period.

After the change took effect, the Pennsylvania Medical Society (PAMED) began hearing from practices whose Medicaid claims for opioid prescriptions are being denied. For the claims PAMED has reviewed, we have found that the denials occurred when the prescriptions exceeded the maximum 5-day supply allowed without prior authorization.

How to Initiate the Prior Authorization Process

Here's what prescribers can to do begin the prior authorization process, when required:

  1. Call the MA Fee-for-Service Program Call Center at 1-800-537-8862, Option 1, between 8 a.m. and 4:30 p.m., Monday through Friday. Or;
  2. Submit a request by fax to 1-866-327-0191. The prescribing provider must submit the completed, signed and dated prior authorization form, along with required supporting documentation of medical necessity. Access the complete list of prior authorization fax forms here.

Once the request has been submitted, the Pa. Department of Human Services' (DHS) prior authorization personnel will review the request to determine whether clinical guidelines have been met. For detailed information about clinical guidelines, access this DHS Medical Assistance Bulletin which outlines the process of prior authorization for opioids.

The prior authorization process will be referred to a physician, peer-to-peer review if guidelines are not met or if the beneficiary is concurrently being prescribed a buprenorphine agent with an FDA-approved indication for opioid dependence or naltrexone for extended-release injectable suspension (Vivitrol).

Authorization of prescriptions for both short-term and long-term opioids will be limited to three (3) months of therapy.

Additional Resources

On Jan. 4, 2017, DHS updated its prior authorization requirements for opiate dependence treatment. This Medical Assistance bulletin offers details.

For MA Program pharmacy prior authorization general requirements, visit this DHS webpage.

PAMED members with questions can contact our Knowledge Center at 855-PAMED4U (855-726-3348) or KnowledgeCenter@pamedsoc.org.

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