568 Medical Assistance program; prior authorization list

DEPARTMENT OF
PUBLIC WELFARE

Medical Assistance Program; Prior Authorization List

[35 Pa.B. 1939]

   The purpose of this notice is to announce that the Department of Public Welfare (Department) will add an item to the Medical Assistance (MA) Program's list of items and services requiring prior authorization.

   Section 443.6(b)(7) of the Public Welfare Code (62 P. S. § 443.6(b)(7)) authorizes the Department to add items and services to the list of services requiring prior authorization by publication of notice in the Pennsylvania Bulletin.

   The MA Program will require prior authorization for prescriptions, including refills, of brand name single source Substance P/Neurokinin 1 Receptor Antagonists and Selective 5-HT3 Receptor Antagonists anti-nausea medications that are greater than the quantity limits established by the Department, dispensed on and after March 28, 2005. The specific medicines in these classes are Anzemet, Emend, Kytril and Zofran, and the quantity limits are as follows. The Department will require prior authorization for additional medicines in these classes, as they become available that exceed quantity limits established by the Department.

Drug	Quantity Limit
Anzemet (dolasetron)
50 mg	14 tabs per 30 days
100 mg	14 tabs per 30 days
Emend (aprepitant)
80 mg	5 tabs per 30 days
125 mg	5 tabs per 30 days
Trifold	2 packs per 30 days
Kytril (granisetron)
1 mg	14 tabs per 30 days
2 mg/10ml	60 ml per 30 days
Zofran (ondansetron)
4 mg	36 tabs per 30 days
8 mg	21 tabs per 30 days
24 mg	7 tabs per 30 days
4 mg/5ml	150 ml per 30 days
4 mg ODT	36 tabs per 30 days
8 mg ODT	21 tabs per 30 days

Fiscal Impact

   The fiscal note was prepared under the authority of section 612 of The Administrative Code of 1929 (71 P. S. § 232).

Public Comment

   Interested persons are invited to submit written comments regarding this notice to the Department of Public Welfare, Office of Medical Assistance Programs, c/o Deputy Secretary's Office, Attention: Regulations Coordinator, Room 515, Health and Welfare Building, Harrisburg, PA 17120. Comments received within 30 days will be reviewed and considered for any subsequent changes to these prior authorization requirements.

   Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Service at [phone] (TDD users) or [phone] (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note:  14-NOT-414. No fiscal impact; (8) recommends adoption.

[Pa.B. Doc. No. 05-568. Filed for public inspection March 25, 2005, 9:00 a.m.]