Medical Assistance Program; Prior Authorization List [35 Pa.B. 2826] This notice announces 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 of Non-Sedating Antihistamines (NSAs), dispensed on and after May 16, 2005, that meet any of the following conditions:
1. The prescription is for an NSA that is not an over- the-counter (OTC) NSA.
2. The prescription is for an OTC NSA and the quantity is greater than the quantity limit established by the Department.
Quantity limits for NSAs established by the Department are as follows:
Drug Quantity Limit Alavert (loratadine) 30 units per 30 days Alavert D (loratadine/pseudoephedrine)
12-hour60 units per 30 days Allegra (fexofenadine)
30mg and 60mg60 units per 30 days Allegra (fexofenadine) 180mg 30 units per 30 days Allegra-D (fexofenadine) 12 Hour 60 units per 30 days Clarinex (desloratadine)
5mg and redi-tabs30 units per 30 days Clarinex (desloratadine) syrup 300ml per 30 days Claritin (loratadine) syrup 300ml per 30 days Claritin (loratadine) tablets 30 units per 30 days Claritin-D (loratadine/pseudoephedrine)
12-hour60 units per 30 days Claritin-D (loratadine/pseudoephedrine)
24-hour30 units per 30 days *Loratadine tablets 30 units per 30 days *Loratadine-D (loratadine/pseudoephedrine)
12-hour60 units per 30 days *Loratadine-D (loratadine/pseudoephedrine)
24-hour30 units per 30 days Zyrtec (cetirizine) 5mg, 10mg 30 units per 30 days Zyrtec (cetirizine) syrup 300ml per 30 days Zyrtec-D (cetirizine/pseudoephedrine)
12 Hour60 units per 30 days * Generic Exceptions
1. Prior authorization of a prescription for Clarinex or Zyrtec for recipients under 2 years of age is not required when the quantity prescribed is at or below the quantity limit established by the Department.
2. Prior authorization of a prescription for an NSA that is not an OTC NSA is not required if the quantity prescribed is at or below the quantity limit established by the Department and the Department has a record of paying for a Loratadine or Loratadine-D product within the past 180 days for the recipient.
The Department will require prior authorization for prescriptions for new NSAs that are not OTC NSAs when they become available in the marketplace.
Fiscal Impact
Due to the claims processing time lag, no savings are anticipated in Fiscal Year (FY) 2004-2005. For FY 2005-2006, savings are estimated at $1.309 million ($0.602 million in State funds).
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 (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-NOT-421. No fiscal impact; (8) recommends adoption. Implementation of the notice will generate savings to the General Fund beginning in Fiscal Year 2005-2006. These savings have been included in the Governor's 2005-2006 proposed budget.
[Pa.B. Doc. No. 05-899. Filed for public inspection May 6, 2005, 9:00 a.m.]
