Medicare AdvantageCoverageHigh impact
26-043 Medicare Part D Formulary Changes: Review Updates for 2026
Health Net·CA·Prior Authorization
Effective date
Jan 1, 2026
We identified it
Jun 20, 2026
Summary
Starting January 1, 2026, several medications will be removed from the Medicare Part D formulary including Humira, Ozempic alternatives, and insulin products. Providers must transition patients to approved formulary alternatives or submit prior authorization requests with medical justification for continued coverage of removed medications.
Action Required
Before January 1, 2026: Clinical team must review patient medication lists to identify those on removed formulary drugs (Humira, Insulin Degludec, Bydureon BCise, etc.) and work with providers to transition to approved alternatives. For patients requiring continuation of removed medications, submit Request for Medicare Drug Coverage Determination forms with detailed medical justification starting January 1, 2026. Forms available at Wellcare portal under Pharmacy Benefits > Coverage Determinations. Contact Pharmacy Services at 800-867-6564 for questions.