MedicaidPrior AuthHigh impact
MAB2026063001
Pennsylvania Medicaid (DHS)·PA · Pulmonology, Pharmacy, Internal Medicine +2 more·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 8, 2026
Summary
Pennsylvania Medical Assistance updated prior authorization requirements for COPD agents effective July 6, 2026. New guidelines add coverage for phosphodiesterase 3 and 4 inhibitors (Daliresp/roflumilast and Ohtuvayre/ensifentrine) with specific clinical criteria including GOLD-guideline-based severity documentation, mental health evaluation requirements, and therapeutic failure documentation. All pharmacies and prescribers enrolled in PA MA must follow updated clinical review guidelines for PA requests.
Action Required
By July 6, 2026: Billing and prior authorization teams must implement updated PA requirements for COPD agents in all systems processing Pennsylvania Medical Assistance claims. Specifically: (1) Pharmacy staff and billing teams must require prior authorization for non-preferred COPD agents, agents exceeding quantity limits, and agents with therapeutic duplication flags; (2) Prescribers submitting PA requests for Daliresp (roflumilast) must document severe COPD per GOLD guidelines AND chronic bronchitis diagnosis (cough/sputum production for 3+ months in 2 consecutive years); (3) Prescribers submitting PA requests for Ohtuvayre (ensifentrine) must document moderate-to-severe COPD per GOLD guidelines AND mMRC Dyspnea Scale score ≥2; (4) For both PDE3/PDE4 inhibitors, providers must document therapeutic failure/contraindication/intolerance to first-line COPD therapy and submit mental health evaluation (psychiatrist for beneficiaries with psychiatric history, prescriber for others); (5) For renewals of PDE3/PDE4 inhibitors, document clinical response (Daliresp: decreased COPD exacerbation frequency; Ohtuvayre: improved pulmonary function, decreased dyspnea severity, decreased rescue inhaler use, or decreased symptom severity); (6) Update PA forms and clinical review workflows to capture new documentation requirements for PDE3/PDE4 inhibitors. Failure to obtain prior authorization will result in claim denials. Reference updated handbook at https://www.pa.gov/agencies/dhs/resources/pharmacy-services/clinical-guidelines.