MedicaidPrior AuthHigh impact
MAB2026070103
Pennsylvania Medicaid (DHS)·PA · Cardiology, Internal Medicine, Endocrinology +1 more·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 2, 2026
Summary
Pennsylvania Medical Assistance updated prior authorization requirements for Lipotropics, Other medications effective July 6, 2026. Changes include new FDA-approved drug Redemplo (plozasiran), revised cholesterol goal metrics (non-HDL-C and apoB), updated statin trial guidelines, modified icosapent ethyl requirements, and new renewal guidelines for non-preferred PCSK9 inhibitors. Pharmacy and prescriber practices must follow updated clinical review guidelines when submitting prior authorization requests.
Action Required
By July 6, 2026: (1) Billing team must update prior authorization submission procedures to comply with revised Lipotropics, Other guidelines in the Medical Assistance Handbook Section II. (2) Verify all PCSK9 inhibitor (alirocumab, evolocumab, inclisiran), ACL inhibitor (bempedoic acid, bempedoic acid/ezetimibe), MTP inhibitor (lomitapide), ANGPTL3 inhibitor (evinacumab), and apoC-III-directed lipotropic (olezarsen, plozasiran) prescriptions require prior authorization. (3) Update claim submission templates and provider documentation requirements to include: lipid profile results within 3 months prior; documentation of statin trial failure or intolerance per new guidelines; evidence of contraindication/intolerance to ezetimibe if applicable; confirmation of concurrent maximum tolerated statin therapy for non-HoFH conditions. (4) Educate providers that prior authorizations for non-preferred PCSK9 inhibitors now require documented failure/contraindication to preferred PCSK9 inhibitors. (5) Ensure pharmacy prior authorization requests reference updated clinical guidelines per 55 Pa. Code § 1101.67(a). Failure to follow revised procedures will result in denial of prior authorization requests and claim rejections. Submit questions to PA Fee-for-Service Provider Service Center: 1-800-537-8862.