MedicaidPrior AuthMedium impact
MAB2021111503
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Cardiology, Rheumatology +2 more·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for oral and inhaled pulmonary hypertension medications, expanding coverage beyond just PAH to all pulmonary hypertension types and revising clinical criteria including new hemodynamic thresholds and specialist consultation requirements.
Action Required
By January 3, 2022: Billing and clinical teams must update prior authorization procedures for pulmonary hypertension medications to reflect new clinical criteria including revised hemodynamic thresholds (mean PA pressure >20 mmHg, PVR ≥3 Wood units), specialist consultation requirements, and expanded coverage for all pulmonary hypertension diagnoses (not just PAH). Update documentation templates to capture new H2 FPEF scores and catheterization data. Pharmacies must follow updated prior auth guidelines or prescriptions will be denied.