MedicaidPrior AuthMedium impact
MAB2025111204
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Pharmacy·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing new prior authorization requirements for ulcerative colitis medications, specifically sphingosine 1-phosphate receptor modulators. All S1PR modulators will require prior authorization effective January 5, 2026, with specific medical necessity criteria including specialist prescriber requirements and step therapy protocols.
Action Required
Before January 5, 2026: Billing team must update prior authorization workflows for all ulcerative colitis medications, particularly sphingosine 1-phosphate receptor modulators. Ensure gastroenterologists are aware of new documentation requirements including proof of therapeutic failure of preferred agents, contraindications, or intolerances. Update billing system to flag all S1PR modulators for prior authorization regardless of preferred status. Train staff on new medical necessity criteria and renewal requirements.