MedicaidPrior AuthMedium impact
MAB2024111205
Pennsylvania Medicaid (DHS)·PA · Oncology, Hematology, Pharmacy·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for oral oncology agents, effective January 6, 2025. The main changes include new requirements to consider therapeutically equivalent brands/generics when evaluating non-preferred drugs, and removal of tolerability guidelines from renewal requests.
Action Required
By January 6, 2025: Billing and clinical teams must update prior authorization workflows for oral oncology agents in Pennsylvania Medicaid patients. Ensure all oral oncology prescriptions have prior authorization from oncologist/hematologist with proper medical necessity documentation. Update renewal processes to remove tolerability requirements and add therapeutic equivalency considerations for non-preferred agents. Claims without proper prior authorization will be denied.