CommercialCoverageHigh impact
Formulary Policy Updates
MVP Health Care·Pharmacy·Pharmacy
We identified it
Jan 1, 2026
Summary
MVP Health Care has published Q1 2026 formulary updates affecting drug coverage for Commercial, Marketplace, and Self-Funded plans. Key changes include: 10 drugs removed from prior authorization requirements, 3 new drugs excluded from coverage, and 6 new generic medications now available. Billing and clinical teams must update prescribing and prior authorization workflows immediately.
Action Required
IMMEDIATE ACTION REQUIRED: (1) Billing team: Remove prior authorization requirements in billing system for the following drugs effective on members' plan year start dates: Grafapex, Xromi, Zunveyl, Inzirqo, Revuforj, Rapiblyk, Tezruly, Zevtera, Avmapki, Emblaveo, Khindivi. (2) Update clinical decision support tools and prior auth workflows to reflect these removals. (3) Add the following drugs to exclusion list in billing system: Alhemo, Raldesy, Vanrafia, Qfitlia, Symbravo—claims for these will be denied. (4) Notify providers that generic alternatives are now available: Rivaroxaban suspension (Xarelto), Topiramate solution (Eprontia), Fidaxomicin tablet (Dificid), Iron Sucrose injection (Venofer), Fluticasone Furoate (Arnuity Ellipta), Liraglutide (Saxenda). (5) Update formulary reference materials provided to clinical staff. Failure to remove prior auth requirements may result in inappropriate denials; failure to identify excluded drugs may result in claim denials or member complaints. Reference official MVP formularies at https://www.mvphealthcare.com/providers/communications-center/formulary-policy-updates/2026-q1-formulary-policy-updates and Provider FastFax Library for complete details.