MedicaidPrior AuthMedium impact
MAB2022120802
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, Internal Medicine +1 more·Provider Bulletin
Effective date
Jan 9, 2023
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) has updated prior authorization requirements for SGLT2 inhibitors used to treat diabetes. The policy removes prior authorization requirements for preferred SGLT2 inhibitors when prescribed within quantity limits, but adds new requirements for therapeutic duplications and maintains requirements for non-preferred drugs.
Action Required
By January 9, 2023: Billing and pharmacy staff must update prior authorization processes for SGLT2 inhibitors in Pennsylvania Medicaid patients. Remove prior auth requirements for preferred SGLT2 inhibitors within quantity limits, but add prior auth requirements when therapeutic duplication occurs (patient has recent paid claim for another SGLT2 inhibitor). Update billing system to check PDL status and recent claim history. For non-preferred drugs, ensure documentation shows therapeutic failure, contraindication, or intolerance to preferred options.