MedicaidPrior AuthMedium impact
MAB2025111201
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Family Medicine, Internal Medicine +2 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is implementing new prior authorization requirements for Proton Pump Inhibitors (PPIs) effective January 5, 2026. The policy requires prior auth for non-preferred PPIs, quantities exceeding limits, pediatric use over 4 months, OTC PPIs for dual-eligible patients, and therapeutic duplications.
Action Required
By January 5, 2026: Update billing system to flag PPI prescriptions requiring prior authorization under Pennsylvania Medicaid. Train staff to identify when prior auth is needed for: non-preferred PPIs, quantities exceeding limits, pediatric patients with 4+ months use in 180 days, OTC PPIs for dual-eligible patients, and therapeutic duplications. Update encounter forms to remind providers of new documentation requirements including FDA-approved indications, appropriate dosing/duration, and medical necessity criteria.