MedicaidPrior AuthMedium impact
MAB2024111402
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 adding new prior authorization requirements for sphingosine 1-phosphate receptor modulators used to treat ulcerative colitis. Providers must obtain prior authorization for all S1PR modulators and meet specific clinical criteria including specialist consultation and step therapy requirements.
Action Required
By January 6, 2025: Billing and clinical teams must update workflows to require prior authorization for all sphingosine 1-phosphate receptor modulator prescriptions for ulcerative colitis patients on Pennsylvania Medicaid. Ensure gastroenterology providers document step therapy failures, contraindications, or intolerances to preferred agents. Update pharmacy prior authorization request procedures to include detailed clinical justification. Claims will be denied without proper prior authorization.