MedicaidPrior AuthMedium impact
mab2024110806
Pennsylvania Medicaid (DHS)·PA · Neurology, PM&R (Physical Medicine & Rehab), Dermatology +2 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing updated prior authorization requirements for botulinum toxins effective January 6, 2025. Key changes include revised criteria for chronic spasticity (focal spasticity and pediatric patients no longer need to fail oral medications first), addition of CGRP-targeting therapies as acceptable prior treatments for chronic migraine, and new renewal requirements including injection site documentation.
Action Required
By January 6, 2025: Billing team must update prior authorization workflows for botulinum toxin prescriptions under Pennsylvania Medicaid. Providers must ensure documentation includes proposed injection sites and doses for each site. For chronic spasticity cases, note that focal spasticity and patients under 18 no longer require oral medication failure documentation. For chronic migraine cases, accept CGRP therapies as qualifying prior treatments. Update PA request templates to include new renewal requirements.