MedicaidPrior AuthHigh impact
July 2026 Preferred Drug List Changes and Other Pharmacy Policy
Wisconsin Medicaid (ForwardHealth)·WI · Pharmacy, Endocrinology, Bariatric Surgery +2 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Aug 26, 2026
Summary
Wisconsin Medicaid is implementing significant pharmacy policy changes effective July 1, 2026, including: (1) establishing a new weight management agents drug class with prior authorization required for all agents, (2) modifying preferred/non-preferred drug status across multiple therapeutic classes, and (3) revising pharmacy-related prior authorization forms and clinical criteria. Billing teams must update systems to enforce prior authorization requirements for weight management agents and transition members from affected non-preferred drugs to preferred alternatives.
Action Required
By June 15, 2026: (1) Billing team must update system configuration to require prior authorization for ALL weight management agents (Foundayo, Zepbound, and Wegovy formulations), even those designated as preferred. (2) Configure system to enforce one weight management agent per member limit and deny claims for duplicate weight management agent therapy. (3) Download and distribute updated PA forms listed in Attachment B to all providers and pharmacy staff. (4) Update pharmacy protocols to obtain BMI documentation and comorbidity verification before submitting PA requests per new clinical criteria (BMI ≥30 OR BMI ≥27 with 2+ risk factors). (5) Create workflow to identify members currently on anti-obesity drugs that will no longer be covered and coordinate transition to covered weight management agents. (6) Train billing, pharmacy, and provider staff on new weight management agent coverage restrictions and PA submission requirements. (7) Update encounter forms and pharmacy templates to reflect requirement for member agreement to follow reduced-calorie diet and increase physical activity. Failure to obtain prior authorization will result in claim denials for weight management agents. Contact Drug Authorization and Policy Override (DAPO) Center at 800-947-9627 for clarification.