MedicaidPrior AuthMedium impact
MAB2025111206
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Rheumatology, Dermatology +3 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing revised prior authorization guidelines for Cytokine and CAM Antagonists (biologics) used to treat conditions like Crohn's disease, ulcerative colitis, and rheumatoid arthritis. The updated requirements include more specific criteria for disease severity, prognostic factors, and specialist consultation requirements.
Action Required
By January 5, 2026: Billing team must update prior authorization workflows for Cytokine and CAM Antagonist prescriptions for Pennsylvania Medicaid patients. Ensure providers document: 1) Specialist consultation (gastroenterologist, rheumatologist, dermatologist, etc.), 2) Disease severity assessment for Crohn's/UC/RA, 3) Infection screening results (TB, Hepatitis B) when required, 4) Contraindication evaluation. Update encounter forms and EMR templates to capture new documentation requirements. Claims will be denied without proper prior authorization.