MedicaidPrior AuthMedium impact
mab2024110805
Pennsylvania Medicaid (DHS)·PA · Psychiatry, Pediatrics, Neurology +1 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for antipsychotic medications effective January 6, 2025. The changes add new guidelines for non-preferred antipsychotics with therapeutically equivalent preferred options and specify that prescriptions exceeding quantity limits require prior authorization.
Action Required
Before January 6, 2025: Billing and clinical teams must update prior authorization workflows for antipsychotic prescriptions. Verify all non-preferred antipsychotics, quantity limit exceedances, pediatric prescriptions (under 18), and therapeutic duplications require prior auth. Update pharmacy billing systems to flag these scenarios. For pediatric cases, ensure proper specialist involvement and comprehensive documentation including baseline monitoring requirements (weight/BMI, blood pressure, glucose, lipid panel, AIMS assessment). Claims without proper prior authorization will be denied.