MedicaidPrior AuthHigh impact
July 2025 Preferred Drug List Changes and Other Pharmacy Policy Changes
Wisconsin Medicaid (ForwardHealth)·WI · Pharmacy, Gastroenterology, Rheumatology +3 more·Pharmacy
Effective date
Jul 1, 2025
We identified it
Aug 26, 2026
Summary
Wisconsin Medicaid (BadgerCare Plus, SeniorCare) updated its Preferred Drug List effective July 1, 2025, with changes to drug status (preferred/non-preferred), new clinical indications for multiple drugs, and modifications to prior authorization requirements across multiple therapeutic classes including cytokine antagonists, H. pylori treatments, GLP-1 hypoglycemics, insulins, asthma immunomodulators, atopic dermatitis treatments, pancreatic enzymes, and skeletal muscle relaxants. Billing teams must update prior authorization workflows and transition processes for affected medications.
Action Required
By June 30, 2025: Billing and pharmacy teams must (1) Review Attachment A of this policy to identify all drug status changes (preferred to non-preferred conversions) affecting your patient population; (2) Update billing system rules to require prior authorization submission for newly non-preferred drugs; (3) Coordinate with prescribing providers to transition patients from previously-preferred drugs that are now non-preferred to current preferred alternatives or prepare PA requests; (4) Update encounter forms and pharmacy dispensing protocols to reflect new PDL status; (5) Review Attachment B for all revised PA forms and instructions, download current versions from ForwardHealth Portal, and replace archived forms in your system; (6) For Tremfya IV claims, ensure procedure code J1628 is included on all prior authorization requests. Before July 1, 2025: Train billing staff on new prior authorization submission options and clinical criteria changes for affected drug classes (cytokine/CAM antagonists, H. pylori, GLP-1 agents, insulins, asthma/atopic dermatitis immunomodulators, pancreatic enzymes, skeletal muscle relaxants). Failure to update workflows will result in claim denials for non-preferred drugs billed without approved prior authorization and processing delays for Tremfya IV without proper procedure coding.