Pharmacy drug policy updates and PA criteria (Kentucky Medicaid highlights)
Customize your policy alerts
Sign up for all medimpact policy alerts
Know when medimpact releases new policies or updates existing guidance.
Monitor payer policy activity
Quarterly pharmacy newsletter summarizing drug recalls, product discontinuations, prior authorization criteria and billing guidance affecting Kentucky Medicaid providers, pharmacies, and payers.
DMS implemented prior authorization criteria for Furoscix Injection Kit effective May 1, 2026, with specific initial and renewal requirements and an 8 kits per 30 days quantity limit.
DMS implemented prior authorization criteria for certain hypertonic saline NDCs effective April 1, 2026, including grandfathering rules for recent claimants.
DMS limited each member to one CGRP inhibitor for acute migraine and one for preventive migraine treatment at a time, effective April 15, 2026.
Prior authorizations approved before January 16, 2026 for Stelara (ustekinumab) will be termed and new PAs for preferred biosimilars (Pyzchiva and Yesintek) were entered effective April 1, 2026.
Dexcom G6 will no longer be manufactured starting July 1, 2026 and providers/pharmacies should transition patients to Dexcom G7 or G7 15 Day.
Insulin degludec (generic for Tresiba) vials and pens have been discontinued and providers should transition patients to covered alternatives on the PDL.
Pulmicort Flexhaler NDCs under certain labeler codes will no longer participate in the Medicaid Drug Rebate Program and therefore will not be covered by Kentucky DMS when supplies are exhausted.
Wegovy coverage restricted to one Wegovy formulation per member as of January 10, 2026, with switching handled by updating existing PA if approval criteria are met.
Stelara claims may be denied after April 1, 2026 if an active prior authorization is not on file; interchangeable biosimilar ustekinumab may be substituted without a new prescription but prescribers must be notified within 5 days.
Interchangeable biosimilar ustekinumab products may be dispensed in place of Stelara® without a new prescription under Kentucky law.
Claims for Stelara® submitted after April 1, 2026, may be denied if an active prior authorization is not on file.
DMS limited members to one Wegovy formulation as of January 10, 2026; a new PA for a different Wegovy formulation will update the previously approved PA if approval criteria are met.
Novo Nordisk discontinued Zegalogue auto-injector and prefilled syringe NDCs; providers should transition patients to covered alternatives.
Coverage Criteria and Limits
inv-01: Furoscix Injection Kit — Initial and Renewal Approval
Covered when ALL of the following are met:
Quantity limit: 8 kits per 30 days
inv-02: Furoscix Renewal Criteria
Renewal covered when ALL of the following are met:
inv-03: Hypertonic Saline Prior Authorization
Covered when criteria are met and PA obtained:
For diagnoses not listed, prescribers encouraged to submit supporting literature
inv-04: CGRP Inhibitor Usage Limit
Coverage stance for CGRP inhibitors:
inv-05: Stelara (ustekinumab) and biosimilar transition
Coverage actions and requirements:
inv-06: Wegovy formulation restriction
Coverage stance:
Effective Jan 10, 2026
inv-07: Payer operational coverage criteria
Coverage subject to the following payer-level requirements and restrictions:
Operational and PA requirements for Stelara/ustekinumab biosimilars
PA criteria available on MedImpact provider portal
Pulmicort Flexhaler NDCs recently introduced under labeler code 85612 do not participate in the Medicaid Drug Rebate Program and therefore will not be covered by the Kentucky Department for Medicaid Services once supplies of currently-covered stock are exhausted. Existing Pulmicort Flexhaler NDCs associated with labeler codes 00186 and 6129 will continue to be covered while supplies last; providers and pharmacies should proactively transition patients to therapeutically appropriate, covered alternatives on the Kentucky Medicaid PDL.
Novo Nordisk has discontinued the Zegalogue auto‑injector and prefilled syringe NDCs listed in the source (NDCs 00169-1912-01, 00169-1912-02, 00169-1913-01, and 00169-1913-02); these products should be transitioned to covered, therapeutically appropriate alternatives per the Kentucky Medicaid Preferred Drug List. Providers and pharmacies should coordinate transitions and may reference the Kentucky Medicaid PDL and MedImpact provider portal for alternative covered therapies and PA guidance.
Covered and Discontinued NDCs / Codes
| 50190014263 | NEBUSAL 3% VIAL NDC |
| 00378699789 | SODIUM CHLORIDE 3% VIAL NDC |
| 50190074060 | PULMOSAL 7% VIAL NDC |
| 50190014123 | SODIUM CHLORIDE 7% VIAL NDC |
| 83490030760 | SODIUM CHLORIDE 7% VIAL NDC |
| NDC 00169-1912-01 | Zegalogue auto-injector/syringe discontinued NDC listed |
| NDC 00169-1912-02 | Zegalogue auto-injector/syringe discontinued NDC listed |
| NDC 00169-1913-01 | Zegalogue auto-injector/syringe discontinued NDC listed |
| NDC 00169-1913-02 | Zegalogue auto-injector/syringe discontinued NDC listed |
What Providers and Pharmacies Must Do
Hypertonic saline — prior authorization required for new starts
Prior authorization is required for members who are new starts on covered hypertonic saline NDCs effective April 1, 2026. Members who had at least one paid claim between November 1, 2025 and February 1, 2026 are grandfathered and have a prior authorization through May 1, 2026; after May 1, 2026 they must obtain a new PA or transition to a different therapy.
- PA effective date for new starts: Apr 1, 2026
- Grandfather window: paid claim between Nov 1, 2025 and Feb 1, 2026 → PA through May 1, 2026
Furoscix prior authorization (effective May 1, 2026)
Furoscix Injection Kit requires prior authorization beginning May 1, 2026. Initial approvals are for 3 months and renewals are 3 months; providers should submit PA requests with the required clinical criteria to MedImpact and reference the Kentucky MedImpact provider portal for forms and guidance.
- Initial approval duration: 3 months; renewal duration: 3 months
- Providers encouraged to obtain PA or identify alternatives for impacted patients
- Reference MedImpact KY provider portal for PA documents and PDL
Zolgensma & Itvisma — route PAs to MedImpact; post-approval MCO billing
All Zolgensma and Itvisma prior authorization requests must be submitted to MedImpact for review and approval. After approval, Managed Care Organization (MCO) members must bill through their MCO using the 837-P/CMS‑1500 and coordinate billing with an approved specialty pharmacy (Accredo Health Group or Orsini Pharmaceutical Services).
- Route all PA requests to MedImpact for review
- MCO billing: submit claim via 837-P/CMS-1500 and coordinate with specialty pharmacy (Accredo or Orsini)
Stelara — active prior authorization required after Apr 1, 2026
An active prior authorization is required for Stelara (ustekinumab) claims submitted after April 1, 2026. Ensure an active PA is on file prior to submitting claims to avoid reimbursement issues.
- PAs approved prior to Jan 16, 2026 were termed and new biosimilar PAs were entered; approvals on/after Jan 16, 2026 remain active
- Interchangeable biosimilar substitution rules and PA requirements affect processing—see notification requirement
Wegovy formulation rule — single formulation per member
Members are limited to a single Wegovy formulation. Submitting a PA for a different Wegovy formulation will, if approval criteria are met, update the previously approved PA to the new formulation.
- Restriction effective Jan 10, 2026: one Wegovy formulation per member
- A new PA for a different formulation replaces the prior approval if criteria are met
CGRP step/limit policy — one acute and one preventive agent
DMS allows use of one CGRP inhibitor for acute migraine treatment and one for preventive migraine treatment at a time. If a prescriber requests switching to a different CGRP formulation and the member meets approval criteria, the existing PA will be updated to the new formulation.
- Each member: one acute CGRP agent and one preventive CGRP agent concurrently
- Switching: approved PA may be updated to new formulation if approval criteria are met
- Nurtec ODT: special handling — soft edit requires confirmation it is not used for the same purpose as a second CGRP agent
Wegovy — step/restriction guidance for switching and renewals
DMS enforces a single‑formulation restriction for Wegovy; providers must submit a PA and follow MedImpact PA criteria for switching or renewals—if a new PA for a different formulation is approved it will replace the prior approval; renewals for the same formulation follow standard renewal criteria.
- Enforcement: one Wegovy formulation per member effective Jan 10, 2026
- Switching: new PA replaces previous PA upon approval
- Renewal: follow standard renewal criteria for same formulation
Furoscix — baseline renal function and electrolyte documentation required
Obtain baseline renal function and electrolytes (serum creatinine/eGFR, BUN, sodium, potassium, bicarbonate) prior to the first Furoscix dose; recent labs are also required for renewal PA requests.
- Baseline labs required before first dose: serum creatinine/eGFR, BUN, sodium, potassium, bicarbonate
- Renewal requires documentation of recent labs within the current authorization period
Furoscix — prescriber attestation required with PA
Prescriber must attest that the patient is hemodynamically stable, a candidate for diuresis outside the hospital, that the medication is for short‑term episodic decongestion with a plan to transition back to oral loop diuretics, and that a documented home management plan is in place when submitting a Furoscix PA.
- Attestation items: hemodynamic stability; candidate for out‑of‑hospital diuresis; short‑term episodic use; transition plan to oral loop diuretics; documented home management plan
Biosimilar dispensing — prescriber notification within 5 days
Pharmacies that dispense an interchangeable ustekinumab biosimilar in place of Stelara must notify the prescriber within five (5) days of dispensing, per Kentucky operational guidance.
- Notification timeframe: within 5 days after dispensing an interchangeable biosimilar
- Interchangeable biosimilars may be dispensed without a new prescription when permitted by law
Wegovy — PA criteria available on MedImpact KY provider portal
MedImpact posts Wegovy PA criteria and supporting documents on the Kentucky provider portal; providers should reference the MedImpact KY provider portal for PA forms and criteria when submitting Wegovy prior authorizations.
- Location: MedImpact provider portal (Kentucky) — https://kyportal.medimpact.com/provider-documents/drug-information
Denial risk — Stelara claims may be denied without active PA after Apr 1, 2026
Claims for Stelara submitted after April 1, 2026 may be denied if an active prior authorization is not on file. Providers should confirm an active PA exists before claim submission to avoid denials.
- Date after which claims may be denied without active PA: Apr 1, 2026
Stelara — high denial risk if active PA not on file after Apr 1, 2026
Failure to have an active prior authorization on file for Stelara after April 1, 2026 poses a high risk of claim denial; ensure PA status is current and coordinate with MedImpact or MCO as appropriate.
- Operational note: PAs approved prior to Jan 16, 2026 were termed; check that a current PA exists
Context and Scope
This quarterly pharmacy newsletter summarizes operational and clinical prior authorization (PA) changes and product discontinuations applicable to Kentucky Medicaid. Key actions include new PA requirements and criteria for the Furoscix Injection Kit (PA effective May 1, 2026; initial and renewal approvals are each for 3 months with a quantity limit of 8 kits per 30 days), prior authorization for select hypertonic saline NDCs effective April 1, 2026 (with limited grandfathering for members with paid claims between Nov 1, 2025 and Feb 1, 2026), and a DMS restriction limiting members to one Wegovy formulation (effective Jan 10, 2026), with PA updates replacing prior approvals when approval criteria are met.
Key Terms
Initial Therapy Requirements
inv-28: Furoscix initial therapy
Initial therapy requirements for Furoscix Injection Kit:
Quantity limit: 8 kits per 30 days
inv-29: Wegovy initial/formulation rule
Initial/formulation rule for Wegovy (semaglutide):
DMS restriction effective Jan 10, 2026
Step Therapy and Switching Rules
| Drug class / indication | Allowed agents | Limit per member | Switching behavior / PA update |
|---|---|---|---|
| CGRP inhibitors — acute migraine | Members may use one CGRP inhibitor for acute treatment (e.g., ubrelvy, other acute agents listed on PDL) | One agent at a time for acute treatment | If a member with an approved PA requests switching to a different formulation, the existing PA will be updated to the new formulation provided approval criteria are met; soft edit requires confirmation when Nurtec ODT is involved |
| CGRP inhibitors — preventive migraine | Members may use one CGRP inhibitor for prevention (e.g., aimovig, ajovy, emgality, qulipta as listed on PDL) | One agent at a time for preventive treatment | If prescriber submits a new PA to switch formulations, the existing PA will be updated to the new formulation if approval criteria are met; Nurtec ODT cannot be combined with two or more CGRP inhibitors for the same purpose |
| Product | Formulation restriction | Limit per member | PA behavior when switching formulations |
|---|---|---|---|
| Wegovy (semaglutide) | Members are limited to a single Wegovy formulation (only one formulation may be active per member) | One Wegovy formulation per member | If a prescriber submits a PA for a different Wegovy formulation and the member meets approval criteria, the previously approved PA will be updated to the new formulation; renewals for the same formulation follow standard renewal criteria; PA criteria available on MedImpact provider portal |
Quantity Limits
Site of Care Requirements
Home administration: patient must be candidate for out-of-hospital diuresis with documented home plan
Patient must be a candidate for diuresis outside the hospital and have a documented home management plan in place before initiating Furoscix for home administration.
- Requirement: documented home management plan (e.g., home weight monitoring) and prescriber attestation that patient is appropriate for home diuresis
Biosimilar Policy and Substitution
Preferred ustekinumab biosimilar PAs entered and active through Dec 31, 2026
Preferred ustekinumab biosimilar PAs (Pyzchiva and Yesintek) were entered for impacted members and approvals are active through December 31, 2026.
- PAs approved through Dec 31, 2026 for impacted members
- PAs approved on or after Jan 16, 2026 for Stelara remain active
Biosimilar PA entries entered for impacted members (verify PA status)
Operational update: new biosimilar PAs were entered for impacted members to facilitate the transition; verify that duplicate or replacement PA entries have been handled appropriately.
- PAs approved prior to Jan 16, 2026 were termed; new biosimilar PAs were entered for affected members
Stelara substitution: interchangeable biosimilar may be dispensed without new Rx; prescriber must be notified within 5 days
Interchangeable ustekinumab biosimilars may be dispensed in place of Stelara without a new prescription under Kentucky law; pharmacies must notify the prescriber within five days after dispensing.
- Dispensing may occur without a new prescription when state law permits substitution
- Prescriber notification required within five (5) days of dispensing
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.