MedicaidPrior AuthMedium impact
MAB2025110604
Pennsylvania Medicaid (DHS)·PA · Psychiatry, Pediatrics, Neurology +1 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing new prior authorization requirements for antipsychotic medications effective January 5, 2026. Key changes include mandatory prior auth for all antipsychotics prescribed to children under 18, new requirements for Opipza (aripiprazole) film, and enhanced metabolic monitoring documentation for drugs with metabolic risk.
Action Required
Before January 5, 2026: Update prior authorization workflows to include new requirements for antipsychotic medications in Pennsylvania Medicaid patients. Ensure providers document age-appropriateness, comprehensive evaluations, specialist consultations (pediatric neurologist, child psychiatrist, or child development pediatrician for patients under 14; expanded specialist list for ages 14+), and baseline metabolic monitoring (weight/BMI, blood pressure, fasting glucose/A1c, lipid panel, EPS using AIMS) for drugs with metabolic risk. Add alerts in EMR for all antipsychotic prescriptions in patients under 18 to trigger prior authorization requests. Failure to obtain prior auth will result in claim denials.