MedicaidPrior AuthMedium impact
MAB2020121405
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Pediatrics·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for all Cystic Fibrosis Transmembrane Regulator (CFTR) Modulators including Trikafta, Kalydeco, Orkambi, and Symdeko. All prescriptions must be prescribed by or in consultation with a pulmonologist or cystic fibrosis specialist and meet specific clinical criteria for approval.
Action Required
By January 5, 2021: Billing team must update prior authorization workflows for all CFTR Modulator prescriptions (Trikafta, Kalydeco, Orkambi, Symdeko) for Pennsylvania Medicaid patients. Ensure prescriptions are from pulmonologists or CF specialists and include required documentation: FDA-approved indication, documented CFTR gene mutation, baseline lab results, and drug interaction assessment. Claims will be denied without proper prior authorization.