MedicaidPrior AuthMedium impact
mab2024110802
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Rheumatology·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is updating prior authorization requirements for Antifibrotic Respiratory Agents effective January 6, 2025. The main change is that when evaluating non-preferred antifibrotic drugs, the program will now consider therapeutically equivalent brands and generics, requiring failure/contraindication to preferred equivalent options.
Action Required
Before January 6, 2025: Providers prescribing antifibrotic respiratory agents to Pennsylvania Medicaid patients must ensure prior authorization requests include documentation of therapeutic failure, contraindication, or intolerance to preferred therapeutically equivalent brands/generics when requesting non-preferred agents. Update prior authorization workflows to include this new requirement. Prescriptions must be by or in consultation with appropriate specialists (pulmonologist, rheumatologist). Claims without proper prior authorization will be denied.