MedicaidPrior AuthMedium impact
MAB2024111402
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Family Medicine, Internal Medicine·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for ulcerative colitis agents, specifically adding new guidelines for sphingosine 1-phosphate receptor (S1PR) modulators. All S1PR modulators now require prior authorization regardless of preferred status, with detailed clinical criteria including specialist prescribing requirements and step therapy protocols.
Action Required
Before January 6, 2025: Billing and clinical teams must update prior authorization procedures for ulcerative colitis medications. All sphingosine 1-phosphate receptor (S1PR) modulators now require prior authorization with gastroenterologist involvement and documented step therapy failures. Update EMR templates to capture required clinical documentation including disease severity, prior treatment failures, and specialist consultation. Train staff on new S1PR modulator criteria and renewal requirements. Claims without proper prior authorization will be denied.