MedicaidPrior AuthHigh impact
MAB2024080701
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, Internal Medicine +2 more·Provider Bulletin
Effective date
Sep 2, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for ALL GLP-1 receptor agonist medications (including preferred ones) used for diabetes or weight management, with specific medical necessity criteria that must be documented. The policy also expands coverage language from 'obesity' to 'overweight or obesity' and adds cardiovascular disease as a qualifying comorbidity.
Action Required
By September 2, 2024: Billing team and providers must obtain prior authorization for ALL GLP-1 receptor agonist prescriptions (semaglutide, liraglutide, etc.) for Pennsylvania Medicaid patients, even if the drug is on the preferred list. Update EMR templates to document required criteria: diabetes diagnosis or BMI ≥30 (or ≥27 with comorbidities like cardiovascular disease, hypertension, diabetes), lifestyle counseling provided, and FDA age/weight appropriateness. Claims will be denied without proper prior authorization.