MedicaidPrior AuthMedium impact
MAB2025111002
Pennsylvania Medicaid (DHS)·PA · Neurology, Gastroenterology, Pharmacy·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for Natalizumab (used for multiple sclerosis and Crohn's disease), with new medical necessity guidelines including specific requirements for Crohn's disease treatment and non-preferred products. All natalizumab prescriptions require prior authorization with detailed clinical criteria that must be met.
Action Required
Before January 5, 2026: Billing team must update prior authorization procedures for all natalizumab prescriptions for Pennsylvania Medicaid patients. Ensure providers document appropriate specialist consultation (neurologist for MS, gastroenterologist for Crohn's), verify step therapy requirements are met, and confirm contraindication documentation is complete. Update billing system to flag all natalizumab claims for prior auth verification. Claims without proper prior authorization will be denied.