MedicaidPrior AuthMedium impact
MAB2021110503
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Dermatology, Rheumatology +3 more·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for Cytokine and CAM Antagonist medications, adding new conditions (atopic dermatitis, sarcoidosis) and revising medical necessity criteria. All prescriptions for these specialty medications must be prior authorized by appropriate specialists.
Action Required
By January 3, 2022: Billing team must ensure all Cytokine and CAM Antagonist prescriptions have prior authorization before dispensing. Update pharmacy systems to flag these medications for PA requirements. Coordinate with prescribing specialists (gastroenterologists, dermatologists, rheumatologists, pulmonologists, oncologists) to obtain proper documentation including tuberculosis screening, hepatitis B testing, and condition-specific treatment history. Claims will be denied without proper prior authorization.