MedicaidPrior AuthMedium impact
MAB2023063004
Pennsylvania Medicaid (DHS)·PA · Oncology, Hematology, Genetics +1 more·Provider Bulletin
Effective date
Jul 10, 2023
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) now requires prior authorization for high-cost specialty drugs including gene therapy, CAR-T therapy, FDA breakthrough/orphan drugs, and accelerated approval medications that are not on the preferred drug list. This applies to fee-for-service Medicaid patients only, not managed care.
Action Required
By July 10, 2023: Billing and clinical teams must identify Pennsylvania Medicaid fee-for-service patients prescribed gene therapy drugs, CAR-T drugs, FDA breakthrough/accelerated approval drugs, or orphan drugs. Providers must obtain prior authorization before prescribing these medications and ensure appropriate specialist consultation and documentation of baseline labs, therapeutic failures, and medical necessity per handbook guidelines. Claims for these drugs will be denied without proper prior authorization.