MedicaidPrior AuthMedium impact
MAB2020121502
Pennsylvania Medicaid (DHS)·PA · Hematology, Oncology, Nephrology +2 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for Complement Inhibitors (including Soliris/eculizumab) to include a new approved indication for neuromyelitis optica spectrum disorder. All prescriptions for these drugs must have prior authorization with specific clinical criteria that must be met.
Action Required
By January 5, 2021: Billing team must ensure all Complement Inhibitor prescriptions (including Soliris/eculizumab) have prior authorization before dispensing for Pennsylvania Medicaid patients. Update prior authorization request procedures to include new neuromyelitis optica spectrum disorder indication and ensure appropriate specialist involvement (hematologist/oncologist, nephrologist, neurologist). Claims will be denied without proper prior authorization.