MedicaidPrior AuthMedium impact
MAB2023111303
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Rheumatology, OB-GYN +3 more·Provider Bulletin
Effective date
Jan 8, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing updated prior authorization guidelines for bone density regulators (osteoporosis medications) including revised criteria for Xgeva and renewal requirements. This affects pharmacy billing and requires specific medical necessity documentation for non-preferred drugs and quantity limit overrides.
Action Required
By January 8, 2024: Billing team must update prior authorization procedures for bone density regulators in Pennsylvania Medicaid cases. Ensure providers document required medical necessity criteria including T-scores, fracture history, contraindications, and secondary osteoporosis evaluation (CBC, vitamin D, calcium, etc.) before prescribing non-preferred medications or quantities exceeding limits. Update EMR templates to include bone density regulator documentation requirements. Claims without proper prior authorization will be denied.