MedicaidPrior AuthMedium impact
MAB2019120405
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Dermatology, Rheumatology +2 more·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for Cytokine and CAM Antagonists effective January 1, 2020. Key changes include new cost-effective preferred products (Renflexis for infliximab, Kineret for IL-1 blockers), updated specialist requirements, and revised clinical guidelines for conditions like Crohn's disease and ulcerative colitis.
Action Required
Before January 1, 2020: Billing team must update prior authorization procedures for Cytokine and CAM Antagonist prescriptions in Pennsylvania Medicaid fee-for-service patients. Ensure prescribers are aware that Renflexis (infliximab-abda) is now the preferred infliximab product and Kineret (anakinra) is preferred for IL-1 blockers. Update pharmacy prior auth forms to reflect new clinical guidelines removing lab monitoring requirements and adding specialist prescriber examples. Claims without proper prior authorization will be denied.