MedicaidPrior AuthMedium impact
MAB2019120605
Pennsylvania Medicaid (DHS)·PA · Ophthalmology, Pharmacy·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) has updated prior authorization requirements for macular degeneration agents effective January 1, 2020. The policy now requires prescriptions from retinal specialists and documentation of therapeutic failure, intolerance, or contraindication to intravitreal bevacizumab, with specific guidelines for preferred vs non-preferred agents.
Action Required
By January 1, 2020: Billing team must update prior authorization procedures for macular degeneration agents to ensure prescriptions are from retinal specialists and include documentation of therapeutic failure, intolerance, or contraindication to intravitreal bevacizumab. Update clinical documentation requirements to include FDA-approved dosing and frequency, previous administration dates for renewals, and tolerability assessments. Note that 5-day emergency supplies are NOT covered for these medications.