MedicaidPrior AuthMedium impact
MAB2020112401
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Rheumatology, Dermatology +2 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for cytokine and CAM antagonists (TNF inhibitors, IL-1 inhibitors, IL-6 inhibitors) used to treat inflammatory conditions like Crohn's disease, ulcerative colitis, rheumatoid arthritis, and adult-onset Still's disease. Key changes include removal of active infection restrictions, revised step therapy requirements for IBD, and addition of guidelines for adult-onset Still's disease treatment.
Action Required
Before January 5, 2021: Billing team and providers must update prior authorization procedures for cytokine and CAM antagonist medications. Ensure specialist consultation documentation is included for all requests. Update clinical documentation requirements to reflect new step therapy guidelines for Crohn's disease and ulcerative colitis. Remove previous active infection restriction requirements from prior auth checklists. Add adult-onset Still's disease treatment guidelines to workflow.