Medicaid Medication Policies


*Statewide Preferred Drug List (PDL)

As of January 1, 2020, all managed care organizations (MCOs) that provided outpatient drug services to Medicaid beneficiaries in Pennsylvania and the State Fee-for-Service (FFS) program were required to use the same Preferred Drug List (PDL). Any drugs designated as non-preferred require prior authorization. In addition, the PA Medicaid MCOs and the FFS program apply the same clinical prior authorization criteria to determine medical necessity for medications included on the PDL. You may access the complete statewide PDL through the Department of Human Services website.

**Please note that all requirements and conditions governing coverage of outpatient drugs, including but not limited to prior authorization criteria, apply whether a drug is provided through the Pharmacy benefit or Medical benefit.



Policy Name
Category
Avastin & Bevacizumab Biosimilars Gateway Health Non-PDL Prior Authorization Criteria
Benlysta Gateway Health Non-PDL Prior Authorization Criteria
Brineura Gateway Health Non-PDL Prior Authorization Criteria
Cough and Cold Medications for Children Under 4 Years of Age Gateway Health Non-PDL Prior Authorization Criteria
Crysvita Gateway Health Non-PDL Prior Authorization Criteria
Cystic Fibrosis Biologic Response Modifiers Gateway Health Non-PDL Prior Authorization Criteria
Daraprim Gateway Health Non-PDL Prior Authorization Criteria
Strensiq Gateway Health Non-PDL Prior Authorization Criteria
Duchenne Muscular Dystrophy (DMD) Antisense Oligonucleotides Gateway Health Non-PDL Prior Authorization Criteria
FreeStyle Libre Continuous Glucose Monitor Systems Gateway Health Non-PDL Prior Authorization Criteria
H.P. Acthar Gel Gateway Health Non-PDL Prior Authorization Criteria
Immune Globulin Products Gateway Health Non-PDL Prior Authorization Criteria
Lumizyme Gateway Health Non-PDL Prior Authorization Criteria
Luxturna Gateway Health Non-PDL Prior Authorization Criteria
Pulmonary Arterial Hypertension (PAH) Agents, Injectable Gateway Health Non-PDL Prior Authorization Criteria
Pulmozyme Gateway Health Non-PDL Prior Authorization Criteria
Radicava Gateway Health Non-PDL Prior Authorization Criteria
Rituxan & Rituximab Biosimilars Gateway Health Non-PDL Prior Authorization Criteria
Somatuline Depot Gateway Health Non-PDL Prior Authorization Criteria
Sublingual Immunotherapy Medications Gateway Health Non-PDL Prior Authorization Criteria
Synagis Gateway Health Non-PDL Prior Authorization Criteria
Zyvox Gateway Health Non-PDL Prior Authorization Criteria
Sandostatin LAR Depot Kit Gateway Health Non-PDL Prior Authorization Criteria
Quantity Limits Gateway Health Non-PDL Prior Authorization Criteria
Non-Formulary Medication/Medical Necessity Gateway Health Non-PDL Prior Authorization Criteria
Zulresso Gateway Health Non-PDL Prior Authorization Criteria
Gamifant Gateway Health Non-PDL Prior Authorization Criteria
Actimmune Gateway Health Non-PDL Prior Authorization Criteria
Myalept Gateway Health Non-PDL Prior Authorization Criteria
Fabry Disease Medications (Fabrazyme & Galafold) Gateway Health Non-PDL Prior Authorization Criteria
Qbrexza Gateway Health Non-PDL Prior Authorization Criteria
Xyrem Gateway Health Non-PDL Prior Authorization Criteria
Phenylketonuria Medications (Kuvan & Palynziq)Gateway Health Non-PDL Prior Authorization Criteria
C5b Complement Inhibitors (Soliris & Ultomiris) Gateway Health Non-PDL Prior Authorization Criteria
Firdapse Gateway Health Non-PDL Prior Authorization Criteria
Nuedexta Gateway Health Non-PDL Prior Authorization Criteria
Xiaflex Gateway Health Non-PDL Prior Authorization Criteria
Sucraid Gateway Health Non-PDL Prior Authorization Criteria
Alpha1-Proteinase Inhibitors Gateway Health Non-PDL Prior Authorization Criteria
Gattex Gateway Health Non-PDL Prior Authorization Criteria
Vyndaqel & Vyndamax Gateway Health Non-PDL Prior Authorization Criteria
Onpattro & Tegsedi Gateway Health Non-PDL Prior Authorization Criteria
Compounds Gateway Health Non-PDL Prior Authorization Criteria
Oncology Medications, IV/Injectable Gateway Health Non-PDL Prior Authorization Criteria
Acne Agents, Oral Statewide PDL Prior Authorization Criteria
Acne Agents, Topical Statewide PDL Prior Authorization Criteria
Alzheimer's Agents Statewide PDL Prior Authorization Criteria
Analgesics, Non-Opioid Barbituate Combinations Statewide PDL Prior Authorization Criteria
Analgesics, Opioid Long Acting Statewide PDL Prior Authorization Criteria
Analgesics, Opioid Short Acting Statewide PDL Prior Authorization Criteria
Androgenic Agents Statewide PDL Prior Authorization Criteria
Angiotensin Modulator Combinations Statewide PDL Prior Authorization Criteria
Angiotensin Modulators Statewide PDL Prior Authorization Criteria
Antianginal Agents Statewide PDL Prior Authorization Criteria
Antibiotics, GI and Related Agents Statewide PDL Prior Authorization Criteria
Antibiotics, Inhaled Statewide PDL Prior Authorization Criteria
Antibiotics, Topical Statewide PDL Prior Authorization Criteria
Antibiotic-Steroid Combinations Statewide PDL Prior Authorization Criteria
Anticoagulants Statewide PDL Prior Authorization Criteria
Anticonvulsants Statewide PDL Prior Authorization Criteria
Antidepressants, Other Statewide PDL Prior Authorization Criteria
Antidepressants, SSRIs Statewide PDL Prior Authorization Criteria
Antiemetics-Antivertigo Agents Statewide PDL Prior Authorization Criteria
Antifungals, Oral Statewide PDL Prior Authorization Criteria
Antifungals, Topical Statewide PDL Prior Authorization Criteria
Antihemophilia Agents Statewide PDL Prior Authorization Criteria
Antihistamines, Minimally Sedating Statewide PDL Prior Authorization Criteria
Antihypertensives, Sympatholytic Statewide PDL Prior Authorization Criteria
Antihyperuricemics Statewide PDL Prior Authorization Criteria
Antimalarials Statewide PDL Prior Authorization Criteria
Antiparasitics, Topical Statewide PDL Prior Authorization Criteria
Antiparkinson's Agents Statewide PDL Prior Authorization Criteria
Antipsoriatics, Oral Statewide PDL Prior Authorization Criteria
Antipsoriatics, Topical Statewide PDL Prior Authorization Criteria
Antipsychotics Statewide PDL Prior Authorization Criteria
Antivirals, CMV Statewide PDL Prior Authorization Criteria
Antivirals, Herpes Statewide PDL Prior Authorization Criteria
Antivirals, Influenza Statewide PDL Prior Authorization Criteria
Anxiolytics Statewide PDL Prior Authorization Criteria
Beta-Blockers Statewide PDL Prior Authorization Criteria
Bile Salts Statewide PDL Prior Authorization Criteria
Bladder Relaxant Preparations Statewide PDL Prior Authorization Criteria
Blood Glucose Meters and Test Strips Statewide PDL Prior Authorization Criteria
Bone Density Regulators Statewide PDL Prior Authorization Criteria
Botulinum Toxins Statewide PDL Prior Authorization Criteria
BPH Treatments Statewide PDL Prior Authorization Criteria
Bronchodilators, Beta Agonists Statewide PDL Prior Authorization Criteria
Calcium Channel Blockers Statewide PDL Prior Authorization Criteria
Cephalosporins Statewide PDL Prior Authorization Criteria
Colony Stimulating Factors Statewide PDL Prior Authorization Criteria
Contraceptives, Oral Statewide PDL Prior Authorization Criteria
Contraceptives, Other Statewide PDL Prior Authorization Criteria
COPD Agents Statewide PDL Prior Authorization Criteria
Cytokine and CAM Antagonists Statewide PDL Prior Authorization Criteria
Dupixent Statewide PDL Prior Authorization Criteria
Enzyme Replacements, Gaucher Disease Statewide PDL Prior Authorization Criteria
Epinephrine, Self-Injected Statewide PDL Prior Authorization Criteria
Erythropoiesis Stimulating Proteins Statewide PDL Prior Authorization Criteria
Estrogens Statewide PDL Prior Authorization Criteria
Fluoroquinolones, Oral Statewide PDL Prior Authorization Criteria
GI Motility, Chronic Statewide PDL Prior Authorization Criteria
Glucocorticoids, Inhaled Statewide PDL Prior Authorization Criteria
Glucocorticoids, Oral Statewide PDL Prior Authorization Criteria
Growth Hormones Statewide PDL Prior Authorization Criteria
H. Pylori Treatments Statewide PDL Prior Authorization Criteria
Hepatitis B Agents Statewide PDL Prior Authorization Criteria
Hepatitis C Agents Statewide PDL Prior Authorization Criteria
Hereditary Angioedema Treatments Statewide PDL Prior Authorization Criteria
Histamine 2 Receptor Blockers Statewide PDL Prior Authorization Criteria
HIV/AIDS Antiretrovirals Statewide PDL Prior Authorization Criteria
Hypoglycemics, Alpha-Glucosidase Inhibitors Statewide PDL Prior Authorization Criteria
Hypoglycemics, Incretin Mimetics/Enhancers Statewide PDL Prior Authorization Criteria
Hypoglycemics, Insulin and Related Agents Statewide PDL Prior Authorization Criteria
Hypoglycemics, Meglitinides Statewide PDL Prior Authorization Criteria
Hypoglycemics, Metformins Statewide PDL Prior Authorization Criteria
Hypoglycemics, SGLT2 Inhibitors Statewide PDL Prior Authorization Criteria
Hypoglycemics, Sulfonylureas Statewide PDL Prior Authorization Criteria
Hypoglycemics, TZDs Statewide PDL Prior Authorization Criteria
Immunomodulators, Atopic Dermatitis Statewide PDL Prior Authorization Criteria
Immunomodulators, Topical Statewide PDL Prior Authorization Criteria
Immunosuppressives, Oral Statewide PDL Prior Authorization Criteria
Intra-Articular Hyaluronates Statewide PDL Prior Authorization Criteria
Intranasal Rhinitis Agents Statewide PDL Prior Authorization Criteria
Iron Chelating Agents Statewide PDL Prior Authorization Criteria
Iron, Parenteral Statewide PDL Prior Authorization Criteria
Leukotriene Modifiers Statewide PDL Prior Authorization Criteria
Lipotropics, Other Statewide PDL Prior Authorization Criteria
Lipotropics, Statins Statewide PDL Prior Authorization Criteria
Local Anesthetics, Topical Statewide PDL Prior Authorization Criteria
Macrolides Statewide PDL Prior Authorization Criteria
Macular Degeneration Agents Statewide PDL Prior Authorization Criteria
Methotrexates Statewide PDL Prior Authorization Criteria
Monoclonal Antibodies (MABs) - Anti-IL, Anti-IgE Statewide PDL Prior Authorization Criteria
Multiple Sclerosis Agents Statewide PDL Prior Authorization Criteria
Neuropathic Pain Statewide PDL Prior Authorization Criteria
NSAIDs Statewide PDL Prior Authorization Criteria
Oncology Agents, Breast Cancer Statewide PDL Prior Authorization Criteria
Oncology Agents, Oral Statewide PDL Prior Authorization Criteria
Ophthalmics, Allergic Conjunctivitis Statewide PDL Prior Authorization Criteria
Ophthalmics, Antibiotics Statewide PDL Prior Authorization Criteria
Ophthalmics, Anti-Inflammatories Statewide PDL Prior Authorization Criteria
Ophthalmics, Glaucoma Statewide PDL Prior Authorization Criteria
Ophthalmics, Immunomodulators Statewide PDL Prior Authorization Criteria
Opioid Dependence Treatments Statewide PDL Prior Authorization Criteria
Opioid Overdose Agents Statewide PDL Prior Authorization Criteria
Otic Antibiotics Statewide PDL Prior Authorization Criteria
Pancreatic Enzymes Statewide PDL Prior Authorization Criteria
Penicillins Statewide PDL Prior Authorization Criteria
Phosphate Binders Statewide PDL Prior Authorization Criteria
Pituitary Suppressive Agents, LHRH Statewide PDL Prior Authorization Criteria
Platelet Aggregation Inhibitors Statewide PDL Prior Authorization Criteria
Potassium Removing Agents Statewide PDL Prior Authorization Criteria
Prenatal Vitamins Statewide PDL Prior Authorization Criteria
Progestational Agents Statewide PDL Prior Authorization Criteria
Proton Pump Inhibitors Statewide PDL Prior Authorization Criteria
Pulmonary Arterial Hypertension (PAH) Agents, Oral and Inhaled Statewide PDL Prior Authorization Criteria
Sedative Hypnotics Statewide PDL Prior Authorization Criteria
Skeletal Muscle Relaxants Statewide PDL Prior Authorization Criteria
Smoking Cessation Statewide PDL Prior Authorization Criteria
Steroids, Topical Statewide PDL Prior Authorization Criteria
Stimulants and Related Agents Statewide PDL Prior Authorization Criteria
Tetracyclines Statewide PDL Prior Authorization Criteria
Thalidomide and Derivatives Statewide PDL Prior Authorization Criteria
Thrombopoietics Statewide PDL Prior Authorization Criteria
Thyroid Hormones Statewide PDL Prior Authorization Criteria
Tysabri Statewide PDL Prior Authorization Criteria
Ulcerative Colitis Agents Statewide PDL Prior Authorization Criteria
Urea Cycle Disorder Agents Statewide PDL Prior Authorization Criteria
Urinary Anti-Infectives Statewide PDL Prior Authorization Criteria
Vaginal Anti-Infectives Statewide PDL Prior Authorization Criteria
Vitamin D Analogs Statewide PDL Prior Authorization Criteria
VMAT2 Inhibitors Statewide PDL Prior Authorization Criteria
Palforzia Gateway Health Non-PDL Prior Authorization Criteria
Givlaari Gateway Health Non-PDL Prior Authorization Criteria
Elaprase Gateway Health Non-PDL Prior Authorization Criteria
Lioresal Gateway Health Non-PDL Prior Authorization Criteria
MACI Gateway Health Non-PDL Prior Authorization Criteria
Naglazyme Gateway Health Non-PDL Prior Authorization Criteria
Quzyttir Gateway Health Non-PDL Prior Authorization Criteria
Tepezza Gateway Health Non-PDL Prior Authorization Criteria
Idiopathic Pulmonary Fibrosis (IPF) Agents Statewide PDL Prior Authorization Criteria
Celestone Soluspan Gateway Health Non-PDL Prior Authorization Criteria
Integrilin Statewide PDL Prior Authorization Criteria
Kenalog Gateway Health Non-PDL Prior Authorization Criteria
Mepsevii Gateway Health Non-PDL Prior Authorization Criteria
Scenesse Gateway Health Non-PDL Prior Authorization Criteria
Uplizna Gateway Health Non-PDL Prior Authorization Criteria
Enspryng Gateway Health Non-PDL Prior Authorization Criteria
Monoferric Gateway Health Non-PDL Prior Authorization Criteria
Bafiertam Gateway Health Non-PDL Prior Authorization Criteria
Kesimpta Gateway Health Non-PDL Prior Authorization Criteria
Spinal Muscular Atrophy Medications Gateway Health Non-PDL Prior Authorization Criteria
Isturisa Gateway Health Non-PDL Prior Authorization Criteria
Migraine Prevention Statewide PDL Prior Authorization Criteria
Sickle Cell Agents Statewide PDL Prior Authorization Criteria
Hematopoietic Mixtures Statewide PDL Prior Authorization Criteria
Migraine Acute Treatment Statewide PDL Prior Authorization Criteria
Hypoglycemia Treatments Statewide PDL Prior Authorization Criteria
Chimeric Antigen Receptor T-cell (CAR-T) Immunotherapy Gateway Health Non-PDL Prior Authorization Criteria
Aduhelm Gateway Health Non-PDL Prior Authorization Criteria

Gateway Health Policy Disclaimer

  • The Policies neither constitutes nor substitutes for medical advice. Gateway Health’s Policies should not be construed as providing medical advice or treatment or guaranteeing the outcome or results of any medical services/treatments and/or procedures Providers are responsible for providing medical advice and treatment, are independent contractors, and are not employees or agents of Gateway Health. If members have a specific question about their medical condition, they should consult with their provider.
  • In the event of a conflict between the Policy and Member Handbook or Evidence of Coverage, the express terms of the Member Handbook or Evidence of Coverage will govern. The existence of a medical guideline is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the medical guideline.  The Policies are used in making decisions as to medical necessity only and they do not guarantee payment of services. Policies serve as one of the sets of guidelines for coverage decisions.
  • The information on this website may not reflect a recent policy change or all of the applicable medical guidelines.

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