MedicaidPrior AuthHigh impact
MAB2020111603
Pennsylvania Medicaid (DHS)·PA · Psychiatry, Neurology, Pediatrics +3 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing new prior authorization requirements for stimulant medications and related agents effective January 5, 2021. Key changes include requiring prior auth for all adults 18+ (except analeptic agents), therapeutic duplications, quantity limit overrides, and updated medical necessity criteria for different drug categories.
Action Required
By January 5, 2021: Update billing system to flag Pennsylvania Medicaid patients 18+ receiving stimulant prescriptions for prior authorization requirements. Train staff on new criteria: non-preferred agents need failure history of preferred drugs, analeptic agents require specific sleep disorder documentation and CPAP failure for sleep apnea, children under 4 need specialist consultation documentation. Update prior auth request forms to include required medical necessity documentation. Claims will be denied without proper prior authorization.