MedicaidPrior AuthHigh impact
MAB2020111206
Pennsylvania Medicaid (DHS)·PA·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated NSAID prior authorization requirements effective January 5, 2021, clarifying when prior auth is needed for ketorolac, removing topical NSAID guidelines, and eliminating automated prior authorization for non-preferred NSAIDs. All prescribers and pharmacies enrolled in PA Medical Assistance must follow new clinical review guidelines for NSAID prescriptions.
Action Required
By January 5, 2021: Billing and clinical teams must update prior authorization protocols for NSAID prescriptions for PA Medicaid patients. Providers must obtain prior auth for: non-preferred NSAIDs per PDL, oral/nasal ketorolac exceeding 5-day supply in 90 days, NSAIDs exceeding quantity limits, and therapeutic duplications. Update EMR templates to document medical necessity including therapeutic failures, contraindications, or intolerances to preferred NSAIDs. Claims without proper prior authorization will be denied.