MedicaidPrior AuthMedium impact
MAB2020110901
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, Internal Medicine +1 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing revised prior authorization requirements for androgenic agents (testosterone and related medications) effective January 5, 2021. Key changes include new guidelines for gender dysphoria diagnosis requiring specialist involvement and adherence to transgender care standards.
Action Required
By January 5, 2021: Billing team and providers must update prior authorization procedures for all androgenic agents prescribed to Pennsylvania Medicaid patients. Ensure documentation includes: 1) Clinical and lab findings for hypogonadism diagnosis, 2) For gender dysphoria cases, verify prescription is by/in consultation with endocrinologist or transgender medicine specialist and follows WPATH standards, 3) For non-preferred agents, document therapeutic failure/contraindication to preferred options. Update encounter forms to prompt for required documentation. Failure to obtain proper prior authorization will result in claim denials.