MedicaidPrior AuthMedium impact
MAB2022120701
Pennsylvania Medicaid (DHS)·PA · Cardiology, Endocrinology, Family Medicine +2 more·Provider Bulletin
Effective date
Jan 9, 2023
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is updating prior authorization requirements for lipotropic medications, including PCSK9 inhibitors, ACL inhibitors, and other cholesterol-lowering drugs. The policy clarifies documentation requirements and adds new guidelines for specific drug classes.
Action Required
By January 9, 2023: Billing and clinical staff must update prior authorization procedures for lipotropic medications in Pennsylvania Medicaid patients. Ensure documentation includes lipid profile results within 3 months, specific cardiovascular diagnoses, and detailed statin trial history for PCSK9 inhibitors. Update prior auth request forms to include new requirements for ezetimibe trials and baseline LDL-C levels ≥190 mg/dL for severe hypercholesterolemia. Claims will be denied without proper documentation.