MedicaidPrior AuthMedium impact
MAB2024111205
Pennsylvania Medicaid (DHS)·PA · Oncology, Hematology, Pharmacy·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for oral oncology medications effective January 6, 2025. The main changes include new consideration of therapeutically equivalent brands/generics when evaluating non-preferred drugs and removal of tolerability requirements for renewal requests.
Action Required
By January 6, 2025: Billing and prior authorization teams must update Pennsylvania Medicaid oral oncology drug authorization procedures. Update prior auth request forms to include documentation of therapeutic failure/contraindication/intolerance to preferred therapeutically equivalent brands or generics for non-preferred drugs. Remove tolerability documentation requirements for renewal requests. Train staff on new medical necessity guidelines requiring oncologist/hematologist prescribing, FDA-approved dosing, and positive clinical response documentation for renewals.