MedicaidPrior AuthMedium impact
MAB2020111302
Pennsylvania Medicaid (DHS)·PA · Endocrinology, OB-GYN, Oncology +1 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing new prior authorization requirements and updated medical necessity guidelines for Pituitary Suppressive Agents (LHRH drugs) effective January 5, 2021. All prescriptions for these medications must now have prior authorization, with specific criteria for conditions like gender dysphoria, endometriosis, and preservation of ovarian function during cancer treatment.
Action Required
By January 5, 2021: Billing and clinical teams must ensure all prescriptions for Pituitary Suppressive Agents (LHRH drugs) have prior authorization before dispensing. Update pharmacy systems to flag these medications as requiring prior auth. Providers must document medical necessity according to the new guidelines including specialist consultation requirements for gender dysphoria cases, therapeutic failure history for endometriosis, and behavioral health assessments for depression history when prescribing Orilissa or Oriahnn. Claims without prior authorization will be denied.