MedicaidPrior AuthHigh impact
MAB2025110601
Pennsylvania Medicaid (DHS)·PA · Endocrinology, Rheumatology, Orthopedics +3 more·Provider Bulletin
Effective date
Jan 5, 2026
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid is implementing new prior authorization requirements for bone density regulators (osteoporosis medications) including preferred bone-modifying monoclonal antibodies and non-preferred drugs. The policy updates medical necessity guidelines with specific clinical criteria for anabolic agents, raloxifene, and other bone density medications.
Action Required
By January 5, 2026: Billing and clinical staff must update prior authorization workflows for Pennsylvania Medicaid bone density regulator prescriptions. Providers must ensure documentation includes secondary osteoporosis evaluation (CBC, vitamin D, calcium, phosphorus, etc.), T-scores, fracture history, and previous treatment failures. Pharmacies must obtain prior auth for non-preferred bone density regulators, preferred bone-modifying monoclonal antibodies, and quantity limit overages. Update PA request forms to include new clinical criteria for anabolic agents and other specific drug requirements. Claims without proper prior authorization will be denied.