MedicaidPrior AuthMedium impact
MAB2022011101
Pennsylvania Medicaid (DHS)·PA · Sleep Medicine, Neurology, Pharmacy·Provider Bulletin
Effective date
Feb 1, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for Xyrem and Xywav (sleep disorder medications), revising substance abuse guidelines, narcolepsy treatment criteria, and adding coverage for idiopathic hypersomnia. The policy also removes urine drug screening requirements for renewals.
Action Required
By February 1, 2022: Billing team must update prior authorization procedures for Xyrem and Xywav prescriptions to include new medical necessity criteria including substance abuse history documentation, PDMP searches, and idiopathic hypersomnia coverage. Providers must document therapeutic failures with specific medications (modafinil, armodafinil, Sunosi, Wakix) before prescribing. Remove urine drug screening requirements for renewal requests in billing system.