MedicaidPrior AuthMedium impact
mab2024111203
Pennsylvania Medicaid (DHS)·PA · Cardiology, Endocrinology, Family Medicine +2 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for lipotropic medications (cholesterol drugs) effective January 6, 2025. The policy removes some previous guidelines for PCSK9 inhibitors and ACL inhibitors while maintaining requirements for prior authorization of non-preferred drugs, quantity limit exceeds, and specific drug classes.
Action Required
By January 6, 2025: Billing and pharmacy teams must update prior authorization procedures for Pennsylvania Medicaid patients receiving lipotropic medications. Review the updated clinical guidelines for PCSK9 inhibitors, ACL inhibitors, MTP inhibitors, and ANGPTL3 inhibitors. Ensure documentation includes lipid profile results within 3 months prior to request and meets new medical necessity criteria. Non-compliance will result in prior authorization denials.