MedicaidPrior AuthMedium impact
MAB2019120601
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Infectious Disease, Family Medicine +1 more·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for antibiotics and GI medications, including new guidelines for Xifaxan (rifaximin) requiring failure of specific first-line treatments like loperamide and bile acid sequestrants for IBS-D, and updated criteria for Zinplava for C. diff infections.
Action Required
By January 1, 2020: Billing team must update prior authorization procedures for antibiotic and GI medications in Pennsylvania Medicaid patients. Providers must document therapeutic failure of azithromycin before prescribing Xifaxan for traveler's diarrhea, and failure of both loperamide and bile acid sequestrants (not antispasmodics) before Xifaxan for IBS-D. Update encounter forms to include these new documentation requirements. Claims may be denied without proper prior authorization.