MAB2026070101

By July 6, 2026: Billing and clinical teams must implement new prior authorization procedures for estrogen prescriptions in the Pennsylvania MA system. (1) Pharmacy staff and billing team: Configure prior auth requirements in billing system to trigger for all non-preferred estrogens and any estrogen prescriptions exceeding quantity limits listed at https://www.pa.gov/agencies/dhs/resources/pharmacy-services/quantity-limits-daily-dose-limits.html. (2) Providers and prescribers: When requesting prior authorization for non-preferred systemic estrogens, document history of therapeutic failure/contraindication/intolerance to preferred systemic options. For non-preferred vaginal estrogens, document history of therapeutic failure/contraindication/intolerance to preferred vaginal options. (3) For gender dysphoria cases: Ensure prescriber is endocrinologist or has experience/training in transgender medicine; verify prescription aligns with WPATH Standards of Care Version 8 (2022). (4) Update internal templates and clinical documentation requirements to capture these elements. Claims lacking required prior authorization will be denied; physician reviewers may override guidelines if medical necessity is documented. Contact PA Fee-for-Service Provider Service Center at 1-800-537-8862 with questions. Reference updated handbook pages in SECTION II at https://www.pa.gov/agencies/dhs/resources/pharmacy-services/clinical-guidelines.