MedicaidPrior AuthMedium impact
MAB2020110606
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Pharmacy, OB-GYN·Provider Bulletin
Effective date
Jan 5, 2021
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is updating prior authorization guidelines for estrogen prescriptions, adding new requirements for gender dysphoria treatment that must be prescribed by specialists with transgender medicine experience. The changes affect pharmacy billing and require specific documentation for coverage approval.
Action Required
By January 5, 2021: Billing team must update prior authorization procedures for estrogen prescriptions in Pennsylvania Medicaid patients. Ensure providers are aware that gender dysphoria cases require prescription by or consultation with endocrinologist or transgender medicine specialist, plus compliance with World Professional Association for Transgender Health standards. Update documentation requirements in billing system to capture specialist involvement and treatment standards compliance for gender dysphoria diagnoses.