MedicaidPrior AuthMedium impact
MAB2020111004
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, General Practice +2 more·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization requirements for diabetes medications (Hypoglycemics, Incretin Mimetics/Enhancers) effective January 5, 2021. New guidelines require specific documentation of FDA-approved use, treatment failures, cardiovascular conditions, and therapeutic duplication justifications.
Action Required
Before January 5, 2021: Update prior authorization procedures for Pennsylvania Medicaid patients requiring diabetes medications (Hypoglycemics, Incretin Mimetics/Enhancers). Ensure documentation includes: FDA-approved indication, HbA1c values showing metformin failure or contraindications, cardiovascular disease status for GLP-1/DPP-4 inhibitors, preferred drug trial history, and justification for any therapeutic duplications. Train clinical staff on new documentation requirements to prevent claim denials.