MedicaidPrior AuthHigh impact
MAB2026070104
Pennsylvania Medicaid (DHS)·PA · Pharmacy·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 8, 2026
Summary
Pennsylvania Medical Assistance updated prior authorization requirements for drugs exceeding quantity limits and daily dose limits effective July 6, 2026. The policy revises clinical review guidelines to address partial-unit dosing, multi-unit consolidation, titration packs, medical reasons for frequent dosing, and documentation of lower-dose ineffectiveness. Prescribers and pharmacies must now submit prior authorization requests that align with these updated criteria.
Action Required
By July 6, 2026: Billing and pharmacy teams must update prior authorization submission procedures and clinical review processes for all drugs on the Quantity Limits/Daily Dose Limits List. (1) Update prior authorization request templates to require documentation supporting one of five criteria: partial-unit dosing needs, multi-unit consolidation impossibility, prescriber-directed titration (within 3 months), medical reason for frequent dosing, or chart documentation showing lower-dose ineffectiveness. (2) Ensure all prior authorization personnel apply the revised clinical guidelines in Section B of the handbook before escalating to physician reviewers. (3) Verify that titration pack considerations are checked against the Statewide Preferred Drug List (PDL) before approving requests. (4) Update internal training materials for billing staff and pharmacy personnel on the new guidelines. (5) Reference the updated Prior Authorization of Pharmaceutical Services Handbook at the provided URLs when processing requests. Failure to follow the updated procedures may result in claim denials or delays in processing prior authorization requests for MA fee-for-service beneficiaries.