Pharmacy Prior Authorization
Pharmacy prior authorizations are required for pharmaceuticals that are not in the formulary, not normally covered, or that have been indicated as requiring prior authorization.
For more information on the pharmacy prior authorization process, call the Pharmacy Services department at 1-844-779-2447.
Important payment notice
Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP) requirement for an approved authorization is determined by satisfying the mandatory requirement to have a valid Pennsylvania Medical Assistance (MA) Provider ID. Effective January 1, 2018, any claim submitted by rendering network providers that are subject to the ORP requirement will be denied when billed with the NPI of an ORP provider that is not enrolled in MA.
To check the MA enrollment status of the practitioner ordering, referring, or prescribing the service you are providing, visit the DHS provider look-up portal.
How to submit a request for pharmacy prior authorization
Online
Save time by submitting all your pharmacy prior authorization requests online. To submit electronically please submit an electronic prior authorization (ePA) through your electronic health record (EHR) tool software, or you can submit through any of the following online portals:
By phone
Call the Pharmacy Services department at 1-844-779-2447. Outside of normal business hours, call Enrollee Services at 1-844-472-2447.
By fax
Requests may be faxed to 1-833-873-2908.
Prior authorization criteria
Many medicines have specific requirements and conditions that must be met to receive prior authorization.