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Pharmacy Updates

Blue Cross Blue Shield of Vermont·VT · Cardiology, Infectious Disease, Oncology +9 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jul 1, 2026
Days to comply
0 days

Summary

Effective July 1, 2026, Blue Cross Vermont is implementing major pharmacy formulary changes affecting 40+ brand-name medications moving to excluded status (with generic alternatives available), 10 products with new quantity limits, 3 drugs requiring new prior authorization, and 6 medications with new step therapy requirements. Billing and clinical teams must immediately identify affected patients and update prior authorization workflows to prevent claim denials.

Action Required

Before Jul 1, 2026
By June 15, 2026: (1) Billing and clinical teams must audit patient medication lists to identify those currently on any of the 40+ newly excluded medications (e.g., Aptiom, Brilinta, Pradaxa, Lyrica, Entresto, Lovenox, Kenalog-10, Nexavar, Tasigna, Victoza, Spiriva, Rytary, Tikosyn, Premarin, Promacta, Korlym, Iressa, and others listed). (2) Pharmacy and clinical staff must proactively contact prescribers and patients to transition to generic formulations or specified alternatives BEFORE July 1 to avoid prior-fill claim denials. (3) Billing system must be updated to flag and require prior authorization for: Arbli (losartan) suspension, Depen (penicillamine) tablets, and Lopressor (metoprolol) solution. (4) Add step therapy requirements in system for: Auryxia, Dymista, Nuvaring (BCBSVT only), Spiriva (BCBSVT only, includes QL), Tiglutik, and Zoryve. (5) Implement quantity limits in billing software for: Albendazole, Biltricide, Emverm, Esbriet, Ivermectin (tablets and Stromectol), Leqembi, Ofev, sodium hyaluronate products, Votrient, and Xdemvy. (6) Update encounter forms and prior authorization templates with new requirements. (7) Brief front desk staff to anticipate patient questions about coverage changes. Failure to implement these changes will result in claim denials, delayed patient access to medications, and potential patient appeals.