Preferred Drug List (PDL) and Pharmacy Quarterly Update

By July 1, 2026: (1) Billing team must update pharmacy billing system to reflect PDL changes—add Starjemza, Wegovy, and Yesintik as preferred drugs with clinical criteria requirements; remove Aricept, Combivent Respimat, Epclusa, and Harvoni from covered formulary; (2) Remove DAW Code 9 option from Elidel in billing software; (3) Update prior authorization workflows to use the new PA Form 373 available at the Medicaid pharmacy forms page; (4) Pharmacy staff must immediately halt use of the Alphabetical PDL and Therapeutic Category PDL documents and transition to the PDL Reference Tool for all lookups; (5) Establish documentation requirements—all claims using OCC-3 (Other Coverage Billed) and DAW-8 (Dispense as Written) must have supporting documentation attached and retained; (6) Training required for all pharmacy billing staff on Medicaid payor-of-last-resort rules and OCC-3 restrictions—clarify that 'Prior Authorization Required' responses from primary insurers do NOT constitute denials and cannot support OCC-3 coding; (7) Implement audit controls to flag claims with OCC-3 and DAW-8 codes for documentation verification before submission. Failure to maintain supporting documentation will result in claim recoupments and potential audit findings.