MedicaidPrior AuthMedium impact
MAB2019120607
Pennsylvania Medicaid (DHS)·PA · Allergy & Immunology, ENT (Ear, Nose & Throat)·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) now requires prior authorization for all oral anti-allergen prescriptions effective January 1, 2020. The policy establishes strict medical necessity criteria including documented failure of multiple first-line treatments and requires prescription by allergy specialists.
Action Required
Before January 1, 2020: Billing team must update prior authorization tracking systems to flag all oral anti-allergen prescriptions for Pennsylvania Medicaid patients. Providers must document therapeutic failure of intranasal glucocorticoids, antihistamines, montelukast, cromolyn sodium, and subcutaneous immunotherapy before prescribing. Ensure prescriptions come from allergists, immunologists, or ENT specialists. Prior authorizations will be approved for maximum 4-month periods requiring renewal documentation.