MedicaidPrior AuthHigh impact
Prior Authorization of Opiate Dependence Treatments - Pharmacy Service MAB 01-17-02
Pennsylvania Medicaid (DHS)·PA · Psychiatry, Pain Management, Family Medicine +1 more·Prior Authorization
Effective date
Jan 4, 2017
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid now requires prior authorization for all buprenorphine prescriptions and other opiate dependence treatments, with specific medical necessity criteria including DSM diagnosis documentation, urine drug screening, and mandatory substance abuse counseling referrals.
Action Required
Immediately: For Pennsylvania Medicaid patients, billing team must obtain prior authorization for ALL buprenorphine prescriptions (including Probuphine implants) and non-preferred opiate dependence treatments. Providers must document DSM criteria, initial urine drug screen results, COWS scores ≥9 for withdrawal cases, signed consent forms, D&A provider evaluations, substance abuse treatment referrals, and mental health screenings before prescribing. Update prior auth request workflows to include these documentation requirements. Claims will be denied without proper prior authorization.