MedicaidPrior AuthHigh impact
MAB2026070103
Pennsylvania Medicaid (DHS)·PA · Cardiology, Endocrinology, Internal Medicine +1 more·Provider Bulletin
Effective date
Jul 6, 2026
We identified it
Jul 8, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for Lipotropics, Other medications effective July 6, 2026. The policy adds new drug classes requiring prior authorization (including the newly FDA-approved Redemplo/plozasiran), revises statin trial requirements, updates cholesterol goal metrics to include non-HDL-C and apoB, and adds renewal guidelines for non-preferred PCSK9 inhibitors. Pharmacies and prescribers must follow updated clinical review guidelines when submitting prior authorization requests.
Action Required
By July 6, 2026: Billing team and pharmacy staff must immediately implement the following changes: (1) Update prior authorization workflows to require PA for all non-preferred Lipotropics medications, any quantity exceeding limits, PCSK9 inhibitors (alirocumab, evolocumab, inclisiran), ACL inhibitors (bempedoic acid, bempedoic acid/ezetimibe), MTP inhibitors (lomitapide), ANGPTL3 inhibitors (evinacumab), and apoC-III-directed drugs (olezarsen, plozasiran); (2) Modify PA request templates to require documentation of lipid profile results within 3 months prior to request and use updated clinical criteria including non-HDL-C and apoB measurements in addition to LDL-C; (3) Train providers and pharmacy staff on revised statin trial requirements and icosapent ethyl treatment guidelines for hypertriglyceridemia; (4) For PCSK9 inhibitor renewals, verify beneficiary meets updated criteria including documentation of statin trial failure, intolerance, or contraindication; (5) Coordinate with managed care organizations for their specific prior authorization processes. Obtain updated handbook pages from PA OMAP website. Failure to implement updated prior authorization requirements will result in claim denials for non-compliant submissions.