MedicaidPrior AuthMedium impact
Prior Authorization of Tetracyclines – Pharmacy Services MAB 01-19-91
Pennsylvania Medicaid (DHS)·PA · Pharmacy, Infectious Disease, Family Medicine +2 more·Prior Authorization
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for tetracycline antibiotics effective January 1, 2020. Non-preferred tetracyclines and quantities exceeding established limits now require prior authorization with specific medical necessity documentation including culture and sensitivity test results.
Action Required
By January 1, 2020: Billing team must verify tetracycline prescriptions against Pennsylvania Medicaid's Preferred Drug List (PDL) and quantity limits before dispensing. Pharmacy staff must obtain prior authorization for non-preferred tetracyclines or quantities exceeding limits. Prescribers must document therapeutic failure, intolerance, contraindications to preferred agents, or provide culture and sensitivity test results supporting non-preferred tetracycline use. Update pharmacy systems to flag tetracyclines requiring prior auth per PA Medicaid guidelines.