Payment conditions for various services - 55 Pa. Code § 1121.52

Medical assistance prescriptions must contain the following information on the prescription form:1

•         The patient’s name and address;
•         The name of the licensed prescriber;
•         The name, strength and quantity of the medication;
•         The directions for use;
•         The number of refills, if any;
•         The indication for “brand medically necessary” when applicable;
•         The DEA number of the licensed provider, when controlled substances have been prescribed; and
•         The professional license number of the licensed prescriber.