MedicaidPrior AuthMedium impact
MAB2024110601
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Dermatology, Rheumatology +3 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing updated prior authorization requirements for Cytokine and CAM Antagonists (specialty medications used for autoimmune conditions) effective January 6, 2025. The changes include revised guidelines for tuberculosis and hepatitis B testing, updated criteria for spesolimab treatment, and new requirements for non-preferred medications with preferred alternatives.
Action Required
By January 6, 2025: Providers prescribing Cytokine and CAM Antagonists for Pennsylvania Medicaid patients must ensure compliance with updated prior authorization guidelines. Review tuberculosis and hepatitis B testing requirements before prescribing. Specialists (gastroenterologists, dermatologists, rheumatologists, etc.) must document medical necessity including appropriate specialist consultation, contraindication screening, and condition-specific criteria for Crohn's disease and ulcerative colitis. Update prior authorization request forms to include new documentation requirements.