Medicare: New non-formulary medication request process
AI Summary
Starting January 1, 2026, Medicare non-formulary medication requests must include progress notes when patients cannot be switched to formulary alternatives. UnitedHealthcare strongly encourages prescribing formulary medications to avoid delays and denials.
Action Required
By January 1, 2026: Providers must include progress notes and comprehensive documentation (medical records showing prior medications tried and failed, clinical rationale for requested medication, relevant clinical details like labs and treatment history) for all Medicare non-formulary medication requests when formulary alternatives are not appropriate. Update EMR templates to prompt for this documentation. Failure to include required documentation may result in delays and denials.
Plan Types
Medicare Advantage, Traditional Medicare
Specialties
all-specialties