Medicare AdvantageDocumentationMedium impact
Medicare: New non-formulary medication request process
UnitedHealthcare·Medicare plan updates
Effective date
Jan 1, 2026
We identified it
Jan 12, 2026
Summary
Starting January 1, 2026, all Medicare non-formulary medication requests for patients who cannot be switched to formulary alternatives must include progress notes and comprehensive medical documentation. This change requires additional documentation to support why formulary alternatives are not appropriate.
Action Required
Before January 1, 2026: Providers must include progress notes and comprehensive medical documentation for all non-formulary medication requests when patients cannot be switched to formulary alternatives. Update EMR templates to include fields for: medical records showing prior medications tried and failed (including formulary alternatives), clinical rationale explaining why formulary alternatives are inappropriate, and relevant clinical details (labs, progress notes, treatment history). Failure to include proper documentation may result in delays and potential denials.