MedicaidPrior AuthMedium impact
MAB2025110705
Pennsylvania Medicaid (DHS)·PA · Allergy & Immunology, Pulmonology, Dermatology +4 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is updating prior authorization requirements for monoclonal antibodies targeting Anti-IL, Anti-IgE, and Anti-TSLP pathways, effective January 5, 2026. The policy clarifies guidelines for non-preferred MABs and requires all prescriptions in this category to obtain prior authorization through updated medical necessity criteria.
Action Required
By January 5, 2026: Billing team must ensure all monoclonal antibody prescriptions (Anti-IL, Anti-IgE, Anti-TSLP including Dupixent, Xolair) for Pennsylvania Medicaid patients have prior authorization before dispensing. Update pharmacy systems to flag these medications for PA requirements. Providers must document specialist consultation, therapeutic failures of preferred agents for non-preferred MABs, and diagnosis-specific criteria (asthma severity, urticaria duration, EGPA confirmation, etc.). Claims will be denied without proper prior authorization.