MedicaidPrior AuthMedium impact
Medical Assistance Bulletin 01-19-24
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Allergy & Immunology, Dermatology +1 more·Provider Bulletin
Effective date
Jan 1, 2020
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid updated prior authorization requirements for Monoclonal Antibodies (Anti-IL, Anti-IgE drugs) including Dupixent, Xolair, and Cinqair. All prescriptions in this drug class now require prior authorization with specific medical necessity criteria for conditions like asthma, chronic urticaria, and eosinophilic granulomatosis.
Action Required
Effective January 1, 2020: Billing team must ensure all prescriptions for MABs Anti-IL/Anti-IgE drugs (including Dupixent, Xolair, Cinqair) have prior authorization before dispensing to Pennsylvania Medicaid patients. Providers must document specialist consultation, appropriate diagnosis criteria, vaccination status, and treatment failure history as specified in the medical necessity guidelines. Claims will be denied without proper prior authorization.