Medicaid Formulary News & Updates

CMS announced the BALANCE (Better Approaches to Lifestyle and Nutrition for Comprehensive hEalth) Model, launching in Medicaid as early as May 2026 for participating states. The voluntary model allows state Medicaid agencies to cover GLP-1 medications for obesity/weight management — an indication previously excluded from most state formularies. Both Novo Nordisk (Wegovy, Ozempic, Rybelsus) and Eli Lilly (Mounjaro, Zepbound) have agreed to participate. Net pricing under the model is negotiated centrally by CMS. Only 13 states currently cover GLP-1s for obesity as of January 2026. States electing to participate in BALANCE must submit applications through CMS. This will create significant formulary and PA changes across participating states — FormCheckRx will reflect coverage changes as each state goes live.

NC Medicaid reinstated coverage of Wegovy (semaglutide) and Zepbound (tirzepatide) for weight management following a prior authorization pathway, reversing the October 1, 2025 removal from the PDL. Saxenda remains non-covered for weight management. GLP-1s continue to be covered for diabetes, cardiovascular disease risk reduction, MASH, and severe obstructive sleep apnea without change. PA criteria require step therapy: patients must try and fail Wegovy before Zepbound or Saxenda will be approved. Prescribers should submit PA requests through NCTracks. NC Medicaid managed care health plans may have delayed system updates — providers should contact individual plans for effective dates.

Michigan's Single Preferred Drug List (SPDL) added Vyalev (foslevodopa and foscarbidopa) vials to the Anti-Parkinson's Agents class as non-preferred with medication-specific clinical criteria. PA criteria require documentation that the patient experiences persistent motor fluctuations with a minimum of 2.5 hours of "off" time per day despite optimized carbidopa/levodopa therapy. Crexont (carbidopa/levodopa) extended-release capsules were also added. Carvedilol ER tablets were moved to non-preferred effective the same date — a 90-day grandfather period applies to existing members to allow transition.

Michigan SPDL moved Entresto Sprinkles (sacubitril/valsartan oral suspension) to non-preferred with a PDL bypass available if the patient is unable to swallow tablets. Entresto tablets remain preferred. Hemangeol (propranolol oral solution) had patient age restriction criteria added — coverage now requires patient age under 1 year. These are off-cycle updates to the Michigan SPDL applicable to all managed care organizations in the state simultaneously.

The Florida Medicaid Preferred Drug List was updated following the December 12, 2025 Pharmacy and Therapeutics Committee meeting. The full PDL (effective April 1, 2026) and a Changes Summary Report are available from AHCA. The Changes Summary Report documents only changes resulting from the December 2025 P&T meeting and does not capture interim changes. Drug Limitation changes (quantity limits, age limits) are published separately. Providers should reference the updated PDL document directly for comprehensive current coverage status on specific drugs.

Effective July 1, 2025, all OneTouch blood glucose test strips and meters are classified as non-preferred on the Mississippi Medicaid Universal PDL. Prescribers should transition patients to a preferred alternative glucose monitoring device. Preferred alternatives are listed on the Mississippi Medicaid PDL. This change affects all Medicaid, MississippiCAN (MSCAN), and CHIP beneficiaries and applies to all managed care plan formularies through the Universal PDL structure.

Texas Medicaid updated its Preferred Drug List effective July 28, 2025. Select medications were moved from preferred to non-preferred status. Non-preferred drugs now require a step therapy prior authorization — members must attempt and fail a preferred medication before a non-preferred drug will be approved. Texas MCOs are required to adhere to the VDP formulary and PDL. Providers should reference txvendordrug.com for the current PDL and initiate preferred medications for new therapy where possible.

Research published in JAMA and covered in Medical Economics (March 2026) found that prior authorization requirements for GLP-1 receptor agonists in Medicare Part D became near-universal in 2025, rising from 2.8–5% of prescriptions in 2020–2023 to nearly 100% in 2025. Average monthly out-of-pocket costs for established GLP-1 drugs rose from $75–$138 in 2024 to $122–$167. Coverage for non-diabetes indications remains minimal — no beneficiaries had coverage for tirzepatide for obstructive sleep apnea; only 1% had coverage for semaglutide for cardiovascular disease. Formulary verification before prescribing GLP-1s is now essential at every plan.

NYRx (New York State Medicaid Pharmacy program) revised its OTC formulary in January 2025 to minimize misuse of high-risk OTC medications. Changes to oxymetazoline and phenylephrine access require providers to transition patients to alternatives including other decongestants or nasal corticosteroids. NYRx noted that recommendations align with current clinical guidelines that favor prescription medications or non-pharmaceutical options over OTC drugs for certain conditions. Members are being notified directly; provider education regarding covered alternatives is recommended.

Foundayo (orforglipron), an oral GLP-1 receptor agonist from Eli Lilly, received FDA approval and was added to the CMS Medicare GLP-1 Bridge eligible drug list effective April 6, 2026. It will be available to eligible Medicare beneficiaries through the GLP-1 Bridge beginning July 1, 2026 alongside Wegovy and Zepbound (KwikPen). Medicaid coverage under the BALANCE Model is anticipated to follow. State Medicaid formulary coverage will vary — FormCheckRx will update state-level coverage as each state goes live. PA criteria will mirror those established for other GLP-1s under the BALANCE model.