MedicaidPrior AuthMedium impact
MAB2023110602
Pennsylvania Medicaid (DHS)·PA · Rheumatology, Dermatology, Gastroenterology +1 more·Provider Bulletin
Effective date
Jan 8, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization guidelines for Cytokine and CAM Antagonist medications, adding new treatment categories including polymyalgia rheumatica, generalized pustular psoriasis flares, and gout flares. All prescriptions for these specialty medications require prior authorization with specific medical necessity criteria.
Action Required
Before January 8, 2024: Billing and clinical teams must ensure all Cytokine and CAM Antagonist prescriptions for Pennsylvania Medicaid patients have prior authorization before dispensing. Providers must document compliance with new medical necessity guidelines including TB/Hepatitis B screening, specialist consultation requirements, and condition-specific criteria for psoriasis, polymyalgia rheumatica, and gout treatments. Claims will be denied without proper prior authorization.