MedicaidPrior AuthMedium impact
MAB2022111005
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 Medicaid is changing prior authorization requirements for diabetes medications (Hypoglycemics, TZDs) effective January 9, 2023. The policy removes prior auth requirements for preferred drugs within quantity limits but adds new requirements for therapeutic duplications and maintains requirements for non-preferred drugs and quantity overages.
Action Required
Before January 9, 2023: Billing and pharmacy teams must update prior authorization workflows for Pennsylvania Medicaid patients on diabetes medications. Remove prior auth requirements for preferred Hypoglycemics/TZDs within quantity limits but add prior auth checks for therapeutic duplications (patients with recent claims for other diabetes medications). Update billing system to flag non-preferred drugs and quantity overages that still require prior authorization. Train staff to document medical necessity for therapeutic duplications including transition plans or clinical reasons for concurrent use.