MedicaidPrior AuthMedium impact
MAB2019120507
Pennsylvania Medicaid (DHS)·PA · Endocrinology, OB-GYN, Pharmacy·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for all Pituitary Suppressive Agents (LHRH drugs) with updated medical necessity criteria including specific guidelines for gender dysphoria treatment and endometriosis. Automated prior authorization has been removed, requiring manual review for all requests.
Action Required
By January 1, 2020: Billing team must update PA systems to require prior authorization for all Pituitary Suppressive Agents/LHRH medications for Pennsylvania Medicaid patients. Remove any automated PA processes for these drugs. Providers must document specific medical necessity criteria including FDA-approved indications, appropriate dosing, contraindication history, and specialist consultation requirements for gender dysphoria and endometriosis cases. Claims will be denied without proper prior authorization.