MedicaidPrior AuthMedium impact
mab2024110602
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Pharmacy·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing new prior authorization requirements for Hepatic and Biliary Agents, including a new category of PPAR agonist drugs like elafibranor. The policy updates medical necessity guidelines and requires specialist consultation for certain medications.
Action Required
Before January 6, 2025: Billing and clinical teams must update prior authorization procedures for Hepatic and Biliary Agents in Pennsylvania Medicaid. Ensure cholic acid and obeticholic acid prescriptions require hepatologist/gastroenterologist consultation. Add new PPAR agonist drugs (like elafibranor) to prior auth requirements with specialist consultation needed. Update documentation requirements to include medical history and lab results supporting diagnosis. Train staff on renewed authorization criteria requiring documented improvement in liver function tests.