MedicaidPrior AuthMedium impact
mab2025110703
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Family Medicine, Internal Medicine +1 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) is updating prior authorization requirements for Continuous Glucose Monitoring (CGM) products, adding a new approval pathway for non-preferred CGMs when they're needed for compatibility with insulin delivery devices. All CGM prescriptions still require prior authorization, but the medical necessity criteria has been expanded.
Action Required
By January 5, 2026: Billing and clinical teams must update prior authorization processes for CGM products for Pennsylvania Medicaid patients. Add compatibility with insulin delivery devices as a new approval criteria for non-preferred CGMs in documentation requirements. Ensure prescribers document either therapeutic failure of preferred CGMs OR insulin device compatibility when requesting non-preferred products. All CGM prescriptions continue to require prior authorization with 12-month approval periods.