MedicaidPrior AuthMedium impact
MAB2025110603
Pennsylvania Medicaid (DHS)·PA · Family Medicine, General Practice, Internal Medicine +3 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for antibiotics, GI and related agents effective January 5, 2026. Key changes include removing Xifaxan (rifaximin) from coverage as the manufacturer left the Medicaid Drug Rebate Program, and removing discontinued Zinplava (bezlotoxumab) from guidelines.
Action Required
By January 5, 2026: Pharmacy and billing teams must update prior authorization processes for antibiotics and GI medications. Stop processing claims for Xifaxan (rifaximin) as it's no longer covered by PA Medicaid. Remove Zinplava (bezlotoxumab) from formulary lists. Review updated clinical guidelines for Dificid (fidaxomicin) requiring high-risk factors, recurrent CDI episodes, or continuation from inpatient discharge. Update billing system to reflect new medical necessity criteria for non-preferred antibiotics and GI agents.