MedicaidPrior AuthMedium impact
MAB2020111303
Pennsylvania Medicaid (DHS)·PA · OB-GYN, 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 new prior authorization requirements for progestational agents, including specific guidelines for intravaginal agents and hydroxyprogesterone caproate. The policy requires prior auth for non-preferred agents, quantities exceeding limits, and all hydroxyprogesterone caproate prescriptions.
Action Required
By January 5, 2021: Billing team must update prior authorization processes for Pennsylvania Medicaid patients receiving progestational agents. Verify preferred drug list status before prescribing non-preferred agents. Ensure documentation includes therapeutic failure/contraindication for preferred agents when requesting non-preferred options. For hydroxyprogesterone caproate, confirm patient meets all criteria (pregnant female, single fetus, 16-36 weeks gestation, history of preterm birth). Claims without proper prior authorization will be denied.