For Providers: Prescription Benefits

PRESCRIPTION BENEFITS

Multiple different public insurance programs in Pennsylvania provide partial or complete coverage for prescription medications.

  • Persons with prescription benefits under Medical Assistance (Medicaid) may be in managed care (HealthChoices) or fee-for service (ACCESS Plus). While most do, not all categories of Medical Assistance cover prescription drugs.
  • Persons eligible for Medicare and Medicaid have primary prescription drug coverage via Medicare Part D. Medicaid is secondary coverage for non-covered drugs under Medicare D, i.e., benzodiazepines and barbiturates. All persons on Medicare and Medicaid are automatically enrolled in a Medicare D plan if they do not choose one. View our Medicare Part D manual.
  • PACE and PACENET are Pennsylvania state programs that offer prescription assistance to people over 65 who are NOT eligible for Medical Assistance. View our PACE/PACENET brochure.
  • Pennsylvania adultBasic insurance does not include prescription benefits.
  • PA Fair Care does include prescription benefits.
  • Persons with HIV or schizophrenia may be eligible for prescription coverage under the Special Pharmaceutical Benefits Program.
  • Persons with chronic renal disease may be eligible for medication help under the Pennsylvania Department of Health Chronic Renal Disease Program.

Prescription help for the uninsured.

Many pharmaceutical companies offer free or discounted medications to low-income individuals who meet certain criteria. Information on these “Prescription Assistance Programs” can be found at these websites:

Medical Assistance Managed Care Formularies

Formularies for Pennsylvanians covered by Medicaid managed care, or HealthChoices, are determined by the respective managed care organizations. Each MCO has its own Pharmacy and Therapeutics Committee. Membership composition and meetings are private.

Procedures for obtaining prior authorization for non-covered medications, or medications requiring prior authorization on clinical grounds, are determined by the managed care organization, in compliance with contracts and Federal law.

Key Information for Physicians regarding Health Choices Formularies

  • Each HMO has a different formulary and different procedures for prior authorization
  • All Medicaid HMOs must follow the same state regulations regarding formulary operations
  • Some plans – but not all – publicly publish criteria for prior authorization of medications

You can prior authorize medications using a letter of medical necessity or a form supplied by the plan. These forms are available in provider handbooks, or online from each plan.

A template that can be attached to a managed care form is available here.

Pennsylvania currently has nine Medicaid managed care plans operating in three mandatory managed care regions (the Southeast, Southwest, and Lehigh/Capital zones). In other areas, there is voluntary participation in one or more of these same HMOs. All plans publish their formularies online:

Fee-for-service Preferred Drug List

Medicaid fee-for-service, sometimes referred to as ACCESS Plus, utilizes the Pennsylvania Preferred Drug List (PDL). The Department of Public Welfare has a Pharmacy and Therapeutics Committee, composed of practicing clinicians and pharmacists, and consumers, who determine drug appropriateness for the PDL. Membership composition is public and meetings are open to the public.

Not all classes of medication are included in the PDL. If a medication class is not on the PDL – for example benzodiazepines – then all FDA approved drugs in that class are available to the Medical Assistance beneficiary. All medications subject to the PDL are listed as either Preferred or Non-Preferred. If they do not appear at all, they are covered.

Specialty drugs – injectables and certain oral chemotherapy agents – must be obtained through two contracted specialty pharmacies. Information is available here.

Procedures for obtaining prior authorization are determined by the Drug Utilization Review Committee, and the Division of Pharmacy in the Department of Public Welfare, in compliance with federal Medicaid law. All criteria for prior authorization are available here.

Click here for the Pennsylvania Fee-for-Service Preferred Drug List

The Pennsylvania Department of Public Welfare Pharmacy website has the following information (and additional information):

  • A chart comparing medications on managed care formularies and the state PDL – useful because it allows plan comparisons, but subject to many inaccuracies because it is only revised yearly. Managed care websites are the most accurate formulary sources for each plan;
  • A search site for all covered drugs under the fee-for-service system;
  • A link to the website for the Preferred Drug List, and;
  • A list of drugs requiring prior authorization, and the prior authorization requirements.

Prior authorization requests under fee-for-service must be done via phone: 1-800-558-4477

Prior authorization and medical necessity

If you are trying to obtain prior authorization, in either Medicaid managed care or fee-for-service, you must demonstrate medical necessity.

  • Click here for the Pennsylvania Medicaid definition of medical necessity.
  • Click here for a template for requesting prior authorization or appealing a denial for a drug.

The Most Important Rules that help your patients get medically necessary medications:

  • DPW or the HMO must respond to a request for prior authorization within 24 hours;
  • DPW or the HMO must allow a pharmacy to dispense a 72 hour supply of any new medication not on formulary for which there is an immediate need. The pharmacist can determine immediate need. If the physician does not complete a prior authorization request the patient will get only this 3 day supply.
  • DPW or the HMO must issue a written denial notice within 24 hours of the time that a non-formulary medication prescription is presented to a pharmacy and a 3 day prescription is filled;
  • DPW or the HMO must allow a pharmacy to dispense a 15 day supply of an ongoing medication unless they have previously sent a written notice of benefit reduction or termination at least 10 days before the old prescription is due to expire. If the member has filed a grievance or fair hearing request the HMO must authorize the pharmacy to dispense the medication until the issue is resolved;
  • DPW or the HMO must cover the medication if you can demonstrate that it is medically necessary;
  • If DPW or HMO denies the medication, the patient, or the practitioner on the patient’s behalf, can appeal. Appeal processes are different under fee-for-service and managed care but the role of the practitioner is the same. Click here for guidance on how to help your patient with an appeal.

Click here for a brochure for patients on prescription rights in Pennsylvania Medical Assistance.

 

Helpline

Having trouble accessing publicly funded health care coverage or services? Call…

1-800-274-3258

or email us at staff@phlp.org.