MEDICAID NEWS
Medicaid Pharmacy Changes Coming January 2026
Beginning January 1, 2026, Medicaid managed care plans (Healthy U, Health Choice Utah, Molina Healthcare, and Select Health Community Care) will be required to align their formularies with the Utah Medicaid preferred drug list (PDL) for certain drug classes selected by the Department of Health and Human Services (Department). This change is being made at the direction of the Utah State Legislature and the Department.
What this means:
- A shared PDL will be used for both Fee-for-Service (FFS) Medicaid (Utah Medicaid) and the managed care plans for specific drug classes.
- Plans will be required to align with Utah Medicaid fee-for-service on utilization management, prior authorization, and clinical criteria for those specific drug classes.
- The Department and each Plan will continue to maintain their own PDLs, which will include preferred drugs from the shared PDL.
Members currently on non-preferred drugs may be required to transition to preferred products. Providers may submit a prior authorization request with a clinical rationale to the appropriate plan to request “grandfathering” of a non-preferred drug.
Drug Classes included on the Medicaid Hybrid PDL:
- Immunomodulators
- CGM/Diabetic Supplies
- Diabetic Continuous Glucose Monitors
- Diabetic Test Strips/Lancets/Monitors
- Atopic Dermatitis (Non-Steroidal)
- Hepatitis C - Direct-Acting Antivirals (DAAs)
- Antidiabetic (Non-insulin)
- DPP-4 Inhibitors
- DPP-4 Inhibitor Combinations
- GLP-1 Agonists
(GLP-1 prescriptions will require a diabetes ICD-10 code of E11#### to process under the Medicaid benefit starting January 1, 2026.) - SGLT2 - Inhibitors
- SGLT2 - Inhibitor Combinations
- Sulfonylurea Combinations
- HIV
- Antiretrovirals - Combination Products
- Antiretrovirals - Entry, Fusion Inhibitors
- Antiretrovirals - Integrase Inhibitors
- Antiretrovirals - Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
- Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs)
- Protease Inhibitors
- Asthma and Bronchodilator Inhaled
- Asthma & COPD - Anticholinergics
- Asthma & COPD - Combination Products
- Asthma & COPD - Corticosteroids
- Asthma & COPD - LABA/LAMA Combinations
- Asthma & COPD - Long-Acting Beta Agonists (LABA)
- Asthma & COPD - Short-Acting Beta Agonists (SABA)
- Antidiabetic (Insulin)
- Insulin Mixtures
- Intermediate Acting Insulin
- Long-Acting Insulin
- Short-Acting Insulin
Impacted members and providers were notified October 1, 2025. Impacted members who are currently on a non-preferred product will be allowed a 90-day transition period. You may receive additional letters through this transition period. We will work with you to ensure members are able to access necessary medication treatments. After January 1, 2026, requests for non-preferred products will be evaluated on a case-by-case basis for medical necessity.
If you have questions, please contact Pharmacy Customer Service for Health Choice Utah at 855-864-1404.Thank you for your cooperation in this transitional period.