MedicaidPrior AuthMedium impact
MAB2023111305
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, Internal Medicine +2 more·Provider Bulletin
Effective date
Jan 8, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for diabetes medications (GLP-1 receptor agonists and incretin mimetics), adding new coverage guidelines for non-preferred GLP-1 medications when used specifically for obesity treatment. The policy now includes specific BMI requirements and weight-related comorbidity criteria for obesity indications.
Action Required
By January 8, 2024: Billing team must update prior authorization procedures for Pennsylvania Medicaid patients receiving GLP-1 receptor agonists for obesity treatment. Ensure documentation includes BMI measurements (≥30 kg/m² for adults 18+, or ≥27 kg/m² with weight-related comorbidities), weight-related comorbidities, lifestyle counseling records, and history of preferred drug failures. Update encounter forms to prompt providers for this documentation. Claims without proper prior authorization will be denied.