MAB2026063001

By July 6, 2026: Billing team, pharmacy staff, and providers must implement new prior authorization requirements for COPD agents in the MA program. (1) Update prior authorization workflows to capture and verify: GOLD COPD severity classification documentation, chronic bronchitis diagnosis (cough/sputum ≥3 months/2 consecutive years) or mMRC Dyspnea Scale score ≥2, history of therapeutic failure/contraindication/intolerance to first-line COPD therapies, exclusion of other airflow obstruction causes, and mental health evaluation status (psychiatrist for high-risk patients; prescriber evaluation for others). (2) For PDE3/PDE4 inhibitors (Daliresp/roflumilast and Ohtuvayre/ensifentrine), require suicidality screening and mental health clearance in prior auth submission forms. (3) For renewal requests, require documentation of decreased COPD exacerbation frequency (Daliresp) or positive clinical response evidence (Ohtuvayre). (4) Update PA request templates to align with current GOLD COPD guidelines. (5) Educate providers and prescribers on new criteria via provider bulletins. (6) Configure billing system to flag non-preferred COPD agents, therapeutic duplications (inhaled glucocorticoids, long-acting anticholinergics, long-acting beta agonists), and quantity limit overages for mandatory prior auth submission. (7) Review Preferred Drug List at https://papdl.com/preferred-drug-list and Quantity Limits list at https://www.pa.gov/agencies/dhs/resources/pharmacy-services/quantity-limits-daily-dose-limits for MA plan updates. Claims submitted without required prior authorization or incomplete clinical documentation will be denied by MA program.