MAB2026070101

By July 6, 2026: Billing team and pharmacy staff must implement new prior authorization procedures for estrogen prescriptions in the PA Medical Assistance program. (1) Update billing system to require prior authorization for: non-preferred estrogens (reference PA PDL at papdl.com) and any estrogen prescription exceeding established quantity limits (reference PA DHS quantity limits list). (2) Providers must obtain prior authorization using SECTION I procedures from the Prior Authorization of Pharmaceutical Services Handbook before dispensing non-preferred estrogens or exceeding quantity limits. (3) Prior authorization reviewers must verify: FDA-approved indication, appropriate dose/duration per FDA labeling or peer-reviewed literature, no contraindications, and therapeutic failure/contraindication/intolerance to preferred alternatives (systemic or vaginal as applicable). (4) For gender dysphoria cases, verify prescriber is endocrinologist or has transgender medicine training and prescribing follows WPATH Standards of Care Version 8. (5) Update encounter forms and clinical review checklists to reflect systemic vs. vaginal estrogen differentiation. (6) Train clinical reviewers on exception process: requests not meeting guidelines must be referred to physician reviewer for medical necessity determination. Failure to obtain required prior authorization will result in claim denials for MA beneficiaries.