MedicaidPrior AuthHigh impact
MAB2025111206
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Rheumatology, Dermatology +3 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing updated prior authorization requirements for Cytokine and CAM Antagonists (biologic medications) used to treat conditions like Crohn's disease, ulcerative colitis, and rheumatoid arthritis. The new guidelines require specialist prescribing, specific documentation of disease severity, infection screening, and other clinical criteria.
Action Required
By January 5, 2026: Update prior authorization workflow for all Cytokine and CAM Antagonist prescriptions for Pennsylvania Medicaid patients. Ensure prescribing providers document: specialist consultation (gastroenterologist, rheumatologist, dermatologist, etc.), disease severity assessment, tuberculosis and hepatitis B screening results, contraindication review, and maintenance therapy justification. Train staff on new medical necessity criteria for Crohn's disease, ulcerative colitis, and rheumatoid arthritis treatments. Failure to meet documentation requirements will result in prior authorization denials.