MedicaidPrior AuthMedium impact
c 277388
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Allergy & Immunology, Dermatology +1 more·Provider Bulletin
Effective date
Jul 23, 2018
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) has added Monoclonal Antibodies - Anti-IL, Anti-IgE drugs (including Cinqair, Nucala, Xolair, and Fasenra) to the Preferred Drug List, requiring prior authorization for all prescriptions. Detailed medical necessity criteria must be met including specialist prescriber requirements, vaccination status, and specific diagnostic criteria for conditions like asthma, chronic idiopathic urticaria, and eosinophilic granulomatosis with polyangiitis.
Action Required
Immediately: Billing and clinical teams must implement prior authorization requirements for all MABs-Anti-IL, Anti-IgE prescriptions (Cinqair, Nucala, Xolair, Fasenra) for Pennsylvania Medicaid patients. Providers must ensure specialist consultation documentation, vaccination records, parasitic infection screening, and diagnosis-specific criteria (eosinophil counts for asthma, IgE levels for Xolair) are documented before prescribing. Update prior authorization workflow to include all 16 medical necessity criteria outlined in the policy.