CommercialCoverageMedium impact
Medica Provider News: March 2026
Medica·Dermatology, Gastroenterology, Rheumatology +1 more·Provider News
Effective date
May 1, 2026
We identified it
Mar 1, 2026
Summary
Effective May 1, 2026, Medica will remove medical benefit coverage for subcutaneous ustekinumab products. Coverage will shift to the pharmacy benefit for commercial, IFB, and integrated pharmacy/medical plans. Billing teams must identify affected claims, verify pharmacy benefit coverage with members' PBMs, and route claims to pharmacy instead of medical for SC ustekinumab on or after the effective date to prevent denials.
Action Required
By April 30, 2026: (1) Billing team must update claim routing logic to route all subcutaneous ustekinumab claims submitted on or after May 1, 2026 to the pharmacy benefit instead of the medical benefit for Medica commercial, IFB, and ASO plans with integrated benefits. (2) Update internal documentation and billing system notes to reflect the medical-to-pharmacy benefit shift for this drug. (3) Notify providers ordering ustekinumab that SC formulations are no longer covered under medical benefits effective May 1, 2026. (4) For each affected member claim, verify pharmacy benefit coverage details with the member's pharmacy benefit manager before claim submission. Failure to route claims correctly will result in medical benefit denials; providers should direct patients to pharmacy coverage or appeal denials with evidence of pharmacy benefit coverage. Note: This change does NOT apply to Medicare Cost or Medicare Supplement plans.