55 Pa. Code § 1121.52 : HUMAN SERVICES — MEDICAL ASSISTANCE MANUAL — Pharmaceutical Services —PAYMENT FOR PHARMACEUTICAL SERVICES — Payment conditions for various services

(a) MA prescriptions, including those for recipients in skilled nursing facilities, intermediate care facilities or intermediate care facilities for the mentally retarded, which have been either written or verbally ordered by a licensed prescriber shall contain on the prescription form:
(1) The name and address of the patient.
(2) The name of the licensed prescriber.
(3) The name, strength and quantity of the medication.
(4) The directions for use.
(5) The number of refills, if any.
(6) The indication for "brand medically necessary", when applicable, as specified in § 1121.53(b) (relating to limitations on payment).
(7) The DEA number of the licensed prescriber, when controlled substances have been prescribed.
(8) The professional license number of the licensed prescriber.
(b) The following service requires prior authorization as specified in § 1101.67 (relating to prior authorization): Each original prescription for single entity and multiple vitamins when prescribed for prenatal use. The Department will automatically issue a prior authorization for prescriptions indicating a diagnosis of pregnancy for single entity and multiple vitamins.
(c) For payment to be made for filling altered prescriptions, the pharmacy shall certify in writing on the prescription that the change was made by the licensed prescriber. Changes in the nature or brand of a medication, the strength of a medication, directions or quantity dispensed are acceptable only if the consent of the prescriber was obtained before dispensing. The written explanation of the pharmacy on the prescription must state that this was done and give the reasons for the change.

55 Pa. Code § 1121.52