MedicaidPrior AuthHigh impact
MAB2024110705
Pennsylvania Medicaid (DHS)·PA · Pain Management, Palliative Care, Oncology +2 more·Provider Bulletin
Effective date
Jan 6, 2025
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing revised prior authorization requirements for long-acting opioid analgesics, with a key change that buprenorphine products are now exempt from requiring documentation of short-acting opioid trials and opioid tolerance. All long-acting opioid prescriptions still require prior authorization with extensive documentation including pain severity, non-opioid trial failures, and urine drug screening results.
Action Required
By January 6, 2025: Providers prescribing long-acting opioids to Pennsylvania Medicaid patients must update prior authorization procedures. For buprenorphine products, providers no longer need to document short-acting opioid trials or opioid tolerance. For all other long-acting opioids, continue requiring documentation of: severe non-migraine pain, non-opioid analgesic failures, short-acting opioid trials, opioid tolerance, risk assessments, recent urine drug screens, and absence of concurrent benzodiazepines unless medically necessary. Update EMR templates and prior authorization forms to reflect these requirements. Claims without proper prior authorization will be denied.