MedicaidPrior AuthHigh impact
MAB2026063003
Pennsylvania Medicaid (DHS)·PA · Neurology, Geriatrics, Psychiatry +1 more·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 1, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) has updated prior authorization requirements for Amyloid-Targeted Monoclonal Antibodies (MABs), effective July 6, 2026. The policy consolidates guidelines for Leqembi (lecanemab-irmb) and Kisunla (donanemab-azbt), removes outdated Aduhelm guidance, and establishes specific clinical criteria including cognitive assessment scores, biomarker confirmation, baseline MRI, dementia specialist prescription, and quarterly monitoring. All prescriptions for these drugs now require prior authorization with documented medical necessity.
Action Required
By July 6, 2026: Billing and prior authorization teams must implement new PA workflows for all Amyloid-Targeted MAB prescriptions (Leqembi and Kisunla). Update prior authorization system to require and verify: (1) FDA-approved indication; (2) at least two cognitive assessment scores (MMSE 18-23, MoCA 18-25, or CDR 0.5-1); (3) FDA-approved dosing; (4) prescriber is dementia specialist with documented quarterly monitoring; (5) baseline MRI results; (6) positive biomarker confirmation (amyloid PET scan, CSF biomarkers, or FDA-cleared plasma biomarker assay); (7) no contraindications to MRI or disqualifying conditions (stroke/TIA/seizures in past year, uncontrolled bleeding disorder, or significant brain pathology on MRI). For renewals, verify continued benefit, repeat cognitive testing results, ongoing quarterly monitoring, and current MRI status. Billing team must update PA request forms and provider communications to reflect consolidated guidelines (remove Aduhelm references). Set up physician review escalation process for cases not meeting guidelines but deemed medically necessary by physician reviewer. Train all staff on new requirements. Failure to obtain prior authorization before dispensing will result in claim denials. Contact PA DHS Fee-for-Service Provider Service Center at 1-800-537-8862 or visit https://www.pa.gov/agencies/dhs/departments-offices/omap-info for questions.