MedicaidPrior AuthMedium impact
mab2024110803
Pennsylvania Medicaid (DHS)·PA · Allergy & Immunology, Pulmonology, Dermatology +3 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for monoclonal antibodies (Anti-IL, Anti-IgE, Anti-TSLP) to prioritize preferred biosimilars and brand biologics. All MAB prescriptions require prior authorization with specific medical necessity criteria including specialist consultation and failure of preferred agents for non-preferred drugs.
Action Required
By January 6, 2025: Billing team must ensure all monoclonal antibody (Anti-IL, Anti-IgE, Anti-TSLP) prescriptions have prior authorization before dispensing. Update systems to flag these medications for PA requirements. Providers must document specialist consultation, appropriate diagnosis, dosing per FDA labeling, and for non-preferred agents, failure of preferred alternatives or current use within 90 days. Review Pennsylvania PDL at papdl.com for preferred drug list. Claims without proper prior authorization will be denied.