MedicaidPrior AuthMedium impact
MAB2025111702
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Cardiology, Pediatrics +1 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for oral and inhaled pulmonary hypertension medications, requiring specific hemodynamic values, specialist consultation, and documentation. All pulmonary hypertension agents now require prior authorization with revised medical necessity guidelines.
Action Required
By January 5, 2026: Billing and clinical staff must update prior authorization procedures for all oral and inhaled pulmonary hypertension medications. Ensure providers document required hemodynamic values (mPAP ≥25 mmHg, PVR >3 Wood units), obtain specialist consultation (pediatric pulmonologist/cardiologist for under 18, accredited center specialist for adults), and complete vasoreactivity testing documentation for idiopathic/heritable PAH patients. Update EMR templates to include required documentation elements. Claims will be denied without proper prior authorization.