MedicaidPrior AuthMedium impact
MAB2022110801
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Infectious Disease, Family Medicine +1 more·Provider Bulletin
Effective date
Jan 9, 2023
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization guidelines for antibiotics and GI medications, removing the requirement for therapeutic failure of a low FODMAP diet before approving certain IBS-D treatments. The policy includes detailed criteria for specific medications like Dificid, Zinplava, and Xifaxan.
Action Required
By January 9, 2023: Billing and prior authorization staff must update Pennsylvania Medicaid prior authorization procedures for antibiotics and GI medications. Remove low FODMAP diet failure documentation requirement for IBS-D treatments. Ensure gastroenterologist consultation is documented for IBS-D prescriptions and specialist consultation for Zinplava prescriptions. Update prior auth forms and staff training materials with new medical necessity criteria.