MedicaidPrior AuthHigh impact
October 2026 Changes for Certain Preferred Drug List Classes and Other Pharmacy Policy
Wisconsin Medicaid (ForwardHealth)·WI · Pharmacy, Endocrinology, Internal Medicine +1 more·Pharmacy
Effective date
Oct 1, 2026
We identified it
Sep 23, 2026
Summary
ForwardHealth implemented three pharmacy policy changes effective October 1, 2026: (1) Lynavoy becomes non-preferred in bile salts class and requires prior authorization with new clinical criteria for cholestatic pruritus; (2) Awiqli becomes non-preferred in long-acting insulins class and requires prior authorization with revised clinical criteria; (3) Clinical criteria for hypoglycemics/long-acting insulins now require documented failure of insulin glargine U-100 and optimization of insulin regimen. Billing teams must update prior authorization workflows and ensure prescribers submit required documentation.
Action Required
By October 1, 2026: (1) Billing team must update pharmacy billing system to flag Lynavoy (bile salts class) and Awiqli (long-acting insulins class) as non-preferred drugs requiring prior authorization. (2) Update prior authorization workflows to require prescribers to submit clinical documentation using form F-11049 (01/2024) for Lynavoy and form F-01749 (07/2024) for Awiqli through the pharmacy, not directly to ForwardHealth. (3) For long-acting insulin PA requests, ensure prescribers document: current insulin regimen, previous regimens, proposed regimen, glycemic goals (HbA1c/FBG targets), and evidence of at least 6 months of insulin glargine U-100 use with inadequate control or hypoglycemic episodes. (4) Communicate to providers that non-adherence, patient/provider preference, and injection volume preference are NOT valid criteria for approval. (5) Update claim scrubbing rules to deny or hold claims for Lynavoy and Awiqli without accompanying prior authorization approval. Consequences: Claims will be denied if prior authorization is not obtained before dispensing.