Formulary Policy Updates

Before the member's 2026 pharmacy plan year start date: (1) Billing team must update pharmacy billing system to remove prior authorization requirements for Blujepa (gepotidacin), Vizz solution 1.44% OP (aceclidine), and Zurnai (nalmefene) for all Commercial, Marketplace, and Self-Funded plan members. (2) Update pharmacy system to flag Brekiya (dihydroergotamine) as excluded/non-covered for Commercial, Marketplace, and Self-Funded formularies; claims for this drug will be denied unless member has prior authorization exception. (3) Pharmacy staff and billing team should review the full 2026 Commercial and Marketplace Formulary Changes document (linked in policy) to identify all additional coverage transitions, including new generic alternatives for Briviact, Edurant, Lumigan, Nucynta, Pomalyst, and Savella. (4) Communicate generic availability to prescribers and patients to reduce claim denials from brand-to-generic transitions. Failure to update system rules will result in inappropriate prior authorization denials for the three removed drugs and inappropriate approvals for the newly excluded Brekiya.