MedicaidPrior AuthMedium impact
MAB2021111005
Pennsylvania Medicaid (DHS)·PA · Pharmacy, Infectious Disease·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (MA) program updated prior authorization requirements for Hepatitis C agents effective January 3, 2022. Key changes include: removal of hepatitis B screening, vaccination, drug interaction screening, life expectancy, and adherence documentation requirements; addition of requirement for documentation of previous hepatitis C treatment regimens for previously treated beneficiaries; and clarification that current use of non-preferred brands does not trigger prior auth when therapeutically equivalent generics are preferred. Billing and pharmacy teams must update prior authorization submission workflows to reflect these simplified clinical review guidelines.
Action Required
By January 3, 2022: Pharmacy team and providers must update prior authorization submission processes for Hepatitis C agents to comply with revised guidelines. Specific actions: (1) Remove from prior authorization requests: hepatitis B screening results, vaccination documentation, drug interaction screening reports, life expectancy documentation, and commitment to adherence statements; (2) Add to prior authorization requests: documentation of previous hepatitis C treatment regimens for beneficiaries with prior treatment history; (3) Update internal documentation checklists and EMR/billing system templates to reflect these changes; (4) Train all pharmacy staff and prescribers on the clarification that non-preferred brand names do not require prior auth when the therapeutically equivalent generic is preferred, and vice versa. Billing team must ensure claims are not denied for missing documentation that is no longer required. Failure to comply will result in prior authorization request denials and delayed claim processing.