MedicaidPrior AuthHigh impact
MAB2019120508
Pennsylvania Medicaid (DHS)·PA · Oncology, Hematology, Pharmacy·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for oral oncology medications, requiring all prescriptions to be prior authorized with new medical necessity guidelines including beneficiary diagnosis, appropriate dosing, and specialist prescribing requirements. New renewal guidelines are also being established for previously approved medications.
Action Required
By January 1, 2020: Billing team must ensure all oral oncology agent prescriptions have prior authorization before dispensing. Update pharmacy systems to flag all oral oncology medications for prior auth requirements. Verify prescriptions are written by or in consultation with oncologists/hematologists and meet dose guidelines per FDA labeling or peer-reviewed literature. For non-preferred agents, document therapeutic failure, contraindication, or intolerance of preferred agents. For renewals, document tolerability and positive clinical response. Failure to obtain prior authorization will result in claim denials.