Clinical Guidelines | Department of Human Services | Commonwealth of Pennsylvania

Clinical Guidelines | Department of Human Services | Commonwealth of Pennsylvania
Pharmacy Services
Prior Authorization Clinical Guidelines
​Related Links
FFS Prior Authorization General Requirements
FFS Prior Authorization Fax Forms
Statewide Preferred Drug List (PDL)
​Statewide PDL Prior Authorization Guidelines
Acne Agents, Oral
Acne Agents, Topical
Alcohol Use Disorder Agents
Alzheimer’s Agents
Analgesics, Acute Pain Agents
Analgesics, Non-Opioid Barbiturate Combinations
Analgesics, Opioid Long-Acting
Analgesics, Opioid Short-Acting
Androgenic Agents
Angiotensin Modulator Combinations
Angiotensin Modulators
Antianginal Agents
Antibiotics, GI and Related Agents
Antibiotics, Inhaled
Antibiotics, Topical
Anticoagulants
Anticonvulsants
Antidepressants, Other
Antidepressants, SSRIs
Antiemetics/Antivertigo Agents
Antifibrotic Respiratory Agents
Antifungals, Oral
Antifungals, Topical
Antihemophilia Agents
Antihistamines, Minimally Sedating
Antihypertensives, Sympatholytic
Antihyperuricemics
Antimalarials
Antiparasitics, Topical
Antiparkinson’s Agents
Antipsoriatics, Oral
Antipsoriatics, Topical
Antipsychotics
Antivirals, CMV
Antivirals, Herpes
Antivirals, Influenza
Anxiolytics
Benign Prostatic Hyperplasia (BPH) Treatments
Beta Blockers
Bladder Relaxant Preparations
Blood Glucose Meters and Test Strips
Bone Density Regulators
Botulinum Toxins
Bronchodilators, Beta Agonists
Calcium Channel Blockers
Cephalosporins
Colony Stimulating Factors
Continuous Glucose Monitoring Products
Contraceptives, Oral
Contraceptives, Other
COPD Agents
Cytokine and CAM Antagonists
Dry Eye Treatments
Dupixent (dupilumab)
Enzyme Replacements, Gaucher Disease
Epinephrine, Self-Administered
Erythropoiesis Stimulating Agents
Estrogens
Fluoroquinolones, Oral
GI Motility, Chronic Agents
GLP-1 Receptor Agonists (formerly Hypoglycemics, Incretin Mimetics/Enhancers)
Glucocorticoids, Inhaled
Glucocorticoids, Oral
Growth Hormones
H. Pylori Treatments
Hematopoietic Mixtures (formerly Iron, Oral)
Hepatic and Bilary Agents
Hepatitis B Agents
Hepatitis C Agents
Hereditary Angioedema (HAE) Agents
Histamine 2 Receptor Blockers
HIV/AIDS Antiretrovirals
Hypoglycemia Treatments
Hypoglycemics, Alpha-Glucosidase Inhibitors
Hypoglycemics, DPP-4 Inhibitors (formerly Hypoglycemics, Incretin Mimetics/Enhancers
Hypoglycemics, Insulin and Related Agents
Hypoglycemics, Meglitinides
Hypoglycemics, Metformins
Hypoglycemics, SGLT2 Inhibitors
Hypoglycemics, Sulfonylureas
Hypoglycemics, TZDs
Immunomodulators, Dermatologics (formerly Immunomodulators, Atopic Dermatitis)
Immunomodulators, Topical
Immunosuppressives, Oral
Intra-Articular Hyaluronates
Intranasal Rhinitis Agents
Iron Chelating Agents
Iron, Parenteral
Leukotriene Modifiers
Lipotropics, Other
Lipotropics, Statins
Local Anesthetics, Topical
Macrolides
Macular Degeneration Agents
Methotrexate
Migraine Acute Treatment Agents
Migraine Prevention Agents
Monoclonal Antibodies (MABs) – Anti-IL, Anti-IgE, Anti-TSLP
Multiple Sclerosis Agents
Natalizumab
Neuropathic Pain Agents
NSAIDs
Obesity Treatment Agents
Oncology Agents, Breast Cancer
Oncology Agents, Oral
Ophthalmics, Allergic Conjunctivitis
Ophthalmics, Antibiotics
Ophthalmics, Antibiotic-Steroid Combinations
Ophthalmics, Anti-Inflammatories
Ophthalmics, Glaucoma
Opioid Overdose Agents
Opioid Use Disorder Treatments
Otic Antibiotic Preparations
Pancreatic Enzymes
Penicillins
Phosphate Lowering Agents
Pituitary Suppressive Agents, LHRH
Platelet Aggregation Inhibitors
Potassium Removing Agents
Prenatal Vitamins
Progestational Agents
Proton Pump Inhibitors (PPIs)
Pulmonary Hypertension Agents, Oral and Inhaled
Sedative Hypnotics
Sickle Cell Anemia Agents
Skeletal Muscle Relaxants
Smoking Cessation Products
Steroids, Topical
Stimulants and Related Agents
Tetracyclines
Thalidomide and Derivatives
Thrombopoietics
Thyroid Hormones
Tubeless Insulin Delivery Devices
Ulcerative Colitis Agents
Urea Cycle Disorder Agents
Urinary Anti-Infectives (formerly Nitrofuran Derivatives)
Vaginal Anti-Infectives (formerly Antibiotics, Vaginal)
Vitamin D Analogs
VMAT2 Inhibitors
Fee-for-Service Non-PDL Prior Authorization Guidelines
Abecma
Adstiladrin
Aqvesme
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Alpha-1 Proteinase Inhibitors (Aralast-NP, Glassia, Prolastin-C, Zemaira)
Amvuttra
Amyloid-Targeted Monoclonal Antibodies (MABs) (Kisunla, Leqembi)
Anti-Allergens, Oral (Grastek, Odactra, Oralair, Ragwitek)
Aphexda
Aqneursa
Attruby
Benlysta
Breyanzi
Brineura
Brinsupri
Bylvay
Camzyos
Carvykti
Casgevy
Clinical Prior Authorization of Non-PDL Drugs
Complement Inhibitors (Bkemv, Empaveli, Enjaymo, Epysqli, Fabhalta, Piasky, Soliris, Tavneos, Ultomiris, Voydeya, Zilbrysq)
Compounded Prescriptions
Corticotropin (formerly H.P. Acthar Gel)
Cough and Cold Medications
Crenessity
Crysvita
Cystaran
Cystic Fibrosis Transmembrane Regulator (CFTR) Modulators (Alyftrek, Kalydeco, Orkambi, Symdeko, Trikafta)
Daybue
DefenCath
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides (Amondys-45, Exondys 51, Viltepso, Vyondys 53)
Duvyzat
Early Refills of Prescriptions
Elevidys
Elitek
Epioxa
Evrysdi
Filspari
Filsuvez
Forzinity
Givlaari
Growth Factors
Harliku
Hyftor
Imaavy
Imcivree
Immune Globulins
Itvisma
Ivabradine
Joenja
Jynarque
Kanuma
Kerendia
Korlym
Kuvan/sapropterin
Kygevvi
Kymriah
Loargys
Lodoco
Livmarli
Lyfgenia
Lynkuet
Mozobil
Myqorzo
Niktimvo
Nuedexta
Omisirge
Onpattro
Palforzia
Palsonify
Palynziq
Provenge
Quantity Limits/Daily Dose Limits
Radicava
Rezdiffra
Rebyota
Rhapsido
Roctavian
Rystiggo
Skyclarys
Skysona
Spinraza
Tecartus
Tecelra
Tepezza
Tzield
Uplizna
Vanrafia
Veozah
Verkazia
Vijoice
Vowst
Voxzogo
Voyxact
Vuity
Vyalev
Vyjuvek
Vyndamax
Vyndaqel
Vykat XR
Vyvgart
Wainua
Winrevair
Xofigo
Xyrem/Xywav
Xolremdi
Yartemlea
Yescarta
Yorvipath
Yuviwel
Zolgensma
Zokinvy
Zycubo
Zynteglo