MedicaidPrior AuthMedium impact
MAB2020111006
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Rheumatology, Pharmacy·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) has updated prior authorization requirements for Idiopathic Pulmonary Fibrosis (IPF) agents, expanding coverage beyond just IPF to include any FDA-approved or medically accepted indication. The policy removes specific requirements for baseline liver function tests and drug-specific guidelines, while simplifying the renewal process.
Action Required
By January 5, 2021: Billing and pharmacy teams must update prior authorization procedures for IPF agents (Esbriet, Ofev) for Pennsylvania Medicaid patients. Ensure prescriptions include documentation of: FDA-approved or medically accepted indication (not limited to IPF), appropriate specialist consultation (pulmonologist/rheumatologist), smoking cessation counseling if applicable, and trial of preferred agents before non-preferred. Remove requirements for baseline liver function testing documentation. Update renewal requests to focus on patient benefit assessment.