As of January 1, 2020, all managed care organizations (MCOs) that provide outpatient drug services to Medicaid beneficiaries in Pennsylvania and the State Fee-for-Service (FFS) program will use the same Preferred Drug List (PDL). Any drugs designated as non-preferred will require prior authorization. In addition, the PA Medicaid MCOs and the FFS program will apply the same clinical prior authorization criteria to determine medical necessity for medications included on the PDL. You may access the complete statewide PDL now through the Department of Human Services website. Beginning January 1, the searchable PDL and prior authorization guidelines will also be located on the Gateway Health, Medicaid website.
You can search the formulary alphabetically by selecting the first letter of the drug you are looking for, or by either the Brand or Generic name of a drug by entering the name of the drug if the first few letters or the full name or correct spelling is not known.
You can also search the formulary by Therapeutic Class of the drug if the exact drug name is not known.
Some of the medications on the formulary require prior authorization, have a quantity limit, must be dispensed by a specialty pharmacy or require step therapy. These medications are marked with a symbol under the Notes & Restrictions column. If the drug you need requires prior authorization, your physician can submit a Drug Specific Prior Authorization Form.If your drug is not included in this formulary, you should first contact Member Services and ask if your drug is covered.A physician may request a non-formulary medication only if medical necessity or failure of formulary alternatives are documented by the physician on the Medicaid Drug Exception Form
• Direct Member Reimbursement Claim Request (DMR)• Specialty Drug List
• Specialty Pharmacy Provider List
• Printable PDF of Statewide Preferred Drug List (PDL) Drug Products
• Printable PDF of Gateway-specific Supplemental Formulary Drug Products
One of our friendly Gateway Health representatives is available to take your call. Monday through Friday, 8 am – 8 pm. 1-800-392-1147 (TTY# 711 for hearing impaired) Or, you can email us.
Page Last Updated on: Tuesday, January 5, 2021
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