MedicaidPrior AuthHigh impact
MAB2020110603
Pennsylvania Medicaid (DHS)·PA · Pain Management, Family Medicine, Internal Medicine +4 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 short-acting opioid analgesics, with stricter guidelines for beneficiaries under 21 and dose limits for high-dose prescriptions. The policy includes specific age-based restrictions and requires prior auth for non-preferred drugs, quantity limit overrides, and therapeutic duplications.
Action Required
By January 5, 2021: Update billing system and pharmacy software to flag short-acting opioid prescriptions requiring prior authorization based on new criteria: non-preferred drugs per PDL, quantity limit overrides, therapeutic duplications, concurrent buprenorphine/Vivitrol, age-based restrictions (under 21 for most opioids, under 18 for codeine/tramadol), and supply limits (3-day max for under 21, 5-day max for 21+). Train prescribers on new medical necessity documentation requirements including alternative pain management trials and PDMP checks. Claims will be denied without proper prior authorization.