MedicaidPrior AuthMedium impact
MAB2020111003
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 now requires prior authorization for all SGLT2 inhibitor diabetes medications effective January 5, 2021. New guidelines allow approval for patients requiring initial dual therapy with metformin or those with cardiovascular disease, heart failure, or chronic kidney disease.
Action Required
By January 5, 2021: Billing and clinical teams must obtain prior authorization for all SGLT2 inhibitor prescriptions for Pennsylvania Medicaid patients. Update clinical documentation templates to capture HbA1c values, metformin trial history, cardiovascular conditions, heart failure, or chronic kidney disease status. Train providers to document medical necessity criteria before prescribing. Claims will be denied without proper prior authorization.