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Commercial and Other Pharmacy Program Updates Effective January 1, 2026
Effective date
Jan 1, 2026
Identified
Jun 16, 2026
Summary
Florida Blue commercial and other pharmacy program updates became effective January 1, 2026. They add drugs to the Responsible Quantity Program with dispensing limits, add drugs to the Prior Authorization Program and the Step Therapy Program, and remove listed brand and generic drugs from pharmacy coverage for members in plans that allow coverage exclusions. Net Results formulary members have separate changes, including new exclusions, drugs added back to coverage, step therapy additions, prior authorization additions and new quantity limits.
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What to do
Action · 8 steps
01Already effective January 1, 2026: Bimzelx Opfolda is excluded from pharmacy coverage, and J1202 will be covered on the medical benefit.
02For members whose plans are part of the Prior Authorization Program, prior authorization requirements changed for the listed drugs, and criteria summaries are available with the authorization forms.
03For Net Results Formulary members, prior authorization requirements changed for the drugs on the Net Results Prior Authorization Program list, and authorization request forms are available at MyPrime.com.
04For members in the Responsible Quantity Program, the listed dispensing limits apply, and they also apply to generic drugs.
05Verify patients' eligibility and pharmacy benefits on Availity Essentials at essentials.availity.com.
06Check the current preferred drug lists at FloridaBlue.com/providers under Tools & Resources, then Medical & Pharmacy Policies, Guidelines, then Medication Guides.
07Direct questions to the Provider Contact Center at 1-800-727-2227.
08Check current applicability of these changes before acting.
Codes mentioned
J1202
Original notice
Commercial and Other Pharmacy Program Updates Effective January 1, 2026
files.guidewell.com · Always check the source before changing claims.
Related changes
See all Florida Blue changes →Commercial and Other Pharmacy Program October 1 UpdatesHighEffective Oct 1, 2026 · PharmacyCommercial and Other Pharmacy Updates Effective October 1, 2025HighEffective Oct 1, 2025 · PharmacyCommercial and Other Pharmacy Updates of April 1HighEffective Apr 1, 2026 · PharmacyCommercial and Other Pharmacy July 1 UpdatesHighEffective Jul 1, 2026 · PharmacyBrowse every Florida Blue change in the policy list