Pennsylvania PA

Pennsylvania (DHS Office of Medical Assistance Programs / OMAP) expresses prior-auth across distinct loci. (1) FFS PHARMACY: canonical harvestable criteria = Statewide PDL Clinical Guidelines page — 126 per-drug-class PDFs, each stating clinical prior-auth criteria for one therapeutic class (current set dated 2026-01-05), administered by OptumRx for DHS-direct FFS. PA has NO statewide pharmacy carve-out; each HealthChoices MCO runs its own PBM but all use the Statewide PDL. (2) FFS MEDICAL: criteria in Medical Assistance provider handbooks (legacy OIM policy manuals services.dpw.state.pa.us/oimpolicymanuals/ma/) + MA Bulletins; processed via PROMISe. (3) MANAGED CARE (6 HealthChoices physical-health zone MCOs): medical PA delegated per-MCO. (4) BH: carved out to county-administered BH-MCOs. (5) LTSS/duals: Community HealthChoices, 3 statewide plans. SITE MIGRATION: DHS moved content from dhs.pa.gov/.../Pages/*.aspx to pa.gov/agencies/dhs/...; old pa_index aspx still 200 but is a shell. Real criteria now under pa.gov/agencies/dhs/resources/pharmacy-services/* and the pa.gov DAM. DAM PDFs open (no bot-wall); direct curl with browser UA works.

carve_in_to_mco_with_uniform_state_pdl_and_pass_through_pricing_mandate

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

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## 1. How Pennsylvania requires prior authorization Pennsylvania's Medicaid (Medical Assistance) program mandates prior authorization for a wide range of services and medications. Requirements are structured across loci within the state's Medicaid system: - **FFS Pharmacy Services**: Prior authorization is required for non-preferred drugs, quantities exceeding limits, compounded prescriptions, and specific therapeutic classes (e.g., anti-allergens, corticotropin, growth hormones). Documentation typically includes medical necessity criteria, clinical history, and adherence to FDA labeling or peer-reviewed literature. - **Managed Care Organizations (MCOs)**: Each physical-health MCO runs its own prior-authorization process within state rules. - **Behavioral Health Services**: Carved out and administered by **county-administered BH MCOs** (HealthChoices BH), so PA processes can vary by county. - **Long-Term Support Services (LTSS)**: Managed through the Community HealthChoices MCO program, distinct from physical-health MCOs. ## 2. How Pennsylvania publishes and reports prior authorization Pennsylvania's Department of Human Services (DHS), Office of Medical Assistance Programs (OMAP), manages publication of prior-authorization criteria: - **Statewide PDL Clinical Guidelines**: For FFS pharmacy, the state publishes per-drug-class clinical guidelines (the sample references on the order of ~126 per-drug-class PDFs) organized by therapeutic category. - **Provider Manuals**: Outline prior-authorization requirements, codes, documentation needs, and effective dates. (A sample summary cited insulin-pump HCPCS E0437/E0438 — those are not insulin-pump codes; treat per-document codes as unreliable.) - **Bulletins**: e.g., the "Clinical PA of Non-PDL Drugs" bulletin and other OMAP/MA bulletins, which carry effective dates and revisions. ## 3. Pennsylvania's CMS-0057-F and prior-authorization-reform compliance posture - **WISeR: Not applicable.** Pennsylvania is **not** a WISeR (CMS "Wasteful and Inappropriate Service Reduction" Medicare PA model) state. The six WISeR states are AZ, NJ, OH, OK, TX, WA. The synthesis's "WISeR pilot status unknown" line implied possible participation and has been corrected. - **CMS-0057-F**: A federal interoperability/PA **rule** Pennsylvania must align with; the state publishes detailed clinical guidelines that support transparency goals. Specific compliance milestones are not detailed in the sample. - **1115 Waivers**: Pennsylvania operates demonstrations (e.g., "Bridges to Success: Keystones of Health" and SUD-related demonstrations) that can carry tailored PA provisions. - **Gold Card Law**: Not detailed in the sample (status unspecified). ## 4. How Pennsylvania runs its own program Pennsylvania operates a combined FFS + managed-care model: - **Fee-for-Service (FFS)**: Used for pharmacy, with statewide clinical guidelines driving consistent PA criteria. - **Physical-Health MCOs (HealthChoices)**: Contracted to manage benefits for most beneficiaries; each runs a compliant PA process. - **Behavioral Health**: County-administered BH MCOs (HealthChoices BH). - **LTSS**: Community HealthChoices MCO program. (A named fiscal-agent transition — ACS-Inc → Conduent/Gainwell — appears in the synthesis but is template-injected and unverified for Pennsylvania.) ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Comprehensive FFS Pharmacy Clinical Guidelines**: Per-drug-class PDFs drive consistency and transparency. - **County-administered BH Carve-out**: A distinctive Pennsylvania feature — behavioral health PA varies by county. - **Community HealthChoices LTSS**: Separate managed LTSS program. ### Missing/Uncertain: - **Program model specifics**: Not fully captured (FFS vs. managed-care split details). - **Foster-care PA process**: Not described in the sample. - **Gold Card Law**: Unspecified. - **Per-document codes**: Unreliable (e.g., the insulin-pump HCPCS error). Overall, Pennsylvania's prior-authorization system is best documented for FFS pharmacy (per-drug-class clinical guidelines) and is distinguished by its county-administered behavioral-health carve-out. Pennsylvania is not a WISeR participant.