MedicaidPrior AuthMedium impact
Prior Authorization of Proton Pump Inhibitors (PPIs) - Pharmacy Services MAB 01-19-93
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Family Medicine, Internal Medicine +2 more·Prior Authorization
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for Proton Pump Inhibitors (PPIs) effective January 1, 2020. The main change clarifies that contraindications will be considered when reviewing requests for non-preferred PPIs or over-the-counter PPIs for dual-eligible beneficiaries.
Action Required
By January 1, 2020: Billing and pharmacy teams must ensure proper prior authorization is obtained for Pennsylvania Medicaid patients receiving: 1) Non-preferred PPIs, 2) PPIs exceeding quantity limits, 3) PPIs for children under 6 years prescribed for 4+ months in 180 days, 4) Over-the-counter PPIs for dual-eligible beneficiaries, and 5) Duplicate PPI therapy. Update billing systems to flag these scenarios and ensure documentation includes contraindications to preferred medications when requesting non-preferred PPIs.