MedicaidPrior AuthMedium impact
MAB2020111005
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 Medicaid updated prior authorization requirements for Hypoglycemic TZD medications, now allowing initial dual therapy with metformin based on HbA1c levels per updated diabetes treatment guidelines. All Hypoglycemic TZDs require prior authorization with specific medical necessity criteria.
Action Required
Before January 5, 2021: Billing team must update prior authorization procedures for all Hypoglycemic TZD prescriptions for Pennsylvania Medicaid patients. Ensure providers document: Type 2 diabetes diagnosis, HbA1c values, metformin trial/contraindication history, or justification for initial dual therapy per ADA/AACE guidelines. For non-preferred TZDs, document therapeutic failure of preferred options. Claims without proper prior authorization will be denied.