MedicaidPrior AuthMedium impact
MAB2023110705
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Infectious Disease, Internal Medicine +2 more·Provider Bulletin
Effective date
Jan 8, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing new prior authorization requirements for Hepatitis C direct-acting antiviral agents when there's therapeutic duplication (multiple DAA agents prescribed concurrently). The policy also updates medical necessity guidelines for non-preferred Hepatitis C agents and quantity limit overrides.
Action Required
By January 8, 2024: Billing and pharmacy staff must update prior authorization protocols to require PA for direct-acting antiviral Hepatitis C agents when therapeutic duplication is detected in the Point-of-Sale system. Review updated medical necessity guidelines including genotyping documentation, cirrhosis assessment, and resistance-associated substitution testing requirements. Ensure prescribers are aware that concomitant DAA use requires medical justification supported by peer-reviewed literature. Claims for therapeutic duplications without prior authorization will be denied.