MedicaidPrior AuthMedium impact
MAB2025111204
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Internal Medicine, Family Medicine·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing new prior authorization requirements for ulcerative colitis medications, specifically sphingosine 1-phosphate receptor modulators. All S1PR modulators for ulcerative colitis treatment will require prior authorization with specific clinical criteria including specialist consultation, severity requirements, and failure of preferred treatments.
Action Required
Before January 5, 2026: Billing team must update prior authorization workflows for ulcerative colitis medications in Pennsylvania Medicaid patients. Ensure all sphingosine 1-phosphate receptor modulators require prior auth regardless of preferred status. Train staff to verify gastroenterologist consultation, document moderate-to-severe UC diagnosis or mild UC with poor prognostic factors, and confirm failure of preferred Cytokine and CAM Antagonists. Claims will be denied without proper prior authorization.