MedicaidPrior AuthMedium impact
MAB2021110804
Pennsylvania Medicaid (DHS)·PA · Nephrology, Hematology, Oncology +2 more·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for Erythropoiesis Stimulating Agents (ESAs) including new specialist consultation requirements, contraindication checks, and specific criteria for different diagnoses. All ESA prescriptions must now meet stricter medical necessity guidelines.
Action Required
By January 3, 2022: Update prior authorization workflows for ESA prescriptions to ensure specialist consultation documentation, contraindication screening, and diagnosis-specific criteria (hemoglobin levels, iron status) are verified before submission. Train billing staff on new renewal requirements including hemoglobin response documentation. Claims without proper prior authorization will be denied.