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Formulary Policy Updates

MVP Health Care·Pharmacy·Pharmacy
Effective date
Not stated
We identified it
Oct 1, 2025
Days to comply

Summary

MVP Health Care has updated its 2025 Q4 formulary, removing prior authorization requirements for 15 medications across commercial, marketplace, and self-funded plans, excluding 5 new drugs from coverage, and adding 20 newly available generic medications to formularies. These changes take effect on each member's plan year start date and require billing teams to update prior authorization workflows and formulary verification processes.

Action Required

Action needed
IMMEDIATE ACTION REQUIRED: (1) Billing team must update prior authorization requirements in all billing software systems to REMOVE prior auth requirements for: Rytelo, Ohtuvayre, Sofdra, Zoryve 0.15% cream, Vafseo, Vigafyde, Voranigo, Crexont, Neffy, Lazcluze, Tryvio, Lodoco, Femlyv, Cobenfy, Vyalev, Itovebi, Aurlumyn, Revuforj, Danziten, Imkeldi, Qlosi, and Journavx (30 tablets per 90 days quantity limit). (2) Billing team must update formulary exclusion lists to ADD: Nemluvio, Onyda XR, Ebglyss, Hympavzi, Opipza, Emrosi, Nypozi, and Alhemo as non-covered for MVP Commercial, Marketplace, and Self-Funded plans. (3) Update all formulary verification tools and prior authorization workflows to reflect these changes effective on each member's plan year start date (typically January 1, 2025 or member-specific plan dates). (4) Notify all providers that prior authorization is no longer required for the 15 removed medications to prevent unnecessary claim delays. (5) Providers must verify coverage before prescribing the 5 newly excluded medications to avoid member cost-sharing issues. Failure to update systems will result in either unnecessary prior authorization denials or coverage denials for excluded drugs.
Formulary Policy Updates | MVP Health Care | PolicyChanges.app