MedicaidPrior AuthMedium impact
MAB2020110907
Pennsylvania Medicaid (DHS)·PA · Allergy & Immunology, Hematology, Dermatology +1 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for Hereditary Angioedema (HAE) medications, adding new clinical criteria including specific lab value requirements, specialist prescriber requirements, and contraindication checks. All HAE agents now require prior authorization with more detailed documentation for medical necessity determination.
Action Required
By January 5, 2021: Billing team must update prior authorization processes for all HAE medications prescribed to Pennsylvania Medicaid patients. Ensure providers obtain prior auth from allergist/immunologist, hematologist, or dermatologist and document required lab values (C4 complement levels and C1 esterase inhibitor levels on two separate occasions for HAE Type I/II). Update encounter forms to include HAE-specific documentation requirements. Claims without proper prior authorization will be denied.