MedicaidPrior AuthMedium impact
MAB2019120404
Pennsylvania Medicaid (DHS)·PA · Dermatology, Allergy & Immunology, Pulmonology +1 more·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for all Dupixent (dupilumab) prescriptions effective January 1, 2020. The policy adds new coverage for chronic rhinosinusitis with nasal polyposis and establishes strict medical necessity criteria including specialist consultation, failed prior treatments, and specific documentation requirements.
Action Required
By January 1, 2020: Billing team and providers must obtain prior authorization for all Dupixent (dupilumab) prescriptions for Pennsylvania Medicaid patients. Ensure prescriptions are written by or in consultation with appropriate specialists (dermatologist, immunologist, allergist, pulmonologist, otolaryngologist). Document therapeutic failure or contraindication to required prior treatments based on diagnosis (topical treatments and phototherapy for atopic dermatitis, systemic glucocorticoids and surgery for chronic rhinosinusitis, maximum asthma controllers for asthma). Claims will be denied without proper prior authorization.