Medicare AdvantagePrior AuthHigh impact
August 2026 UPMC for You and UPMC Community HealthChoices Formulary Updates
UPMC Health Plan·PA · Endocrinology, Ophthalmology, Gastroenterology·Pharmacy
Effective date
Aug 15, 2026
We identified it
Jul 10, 2026
Summary
Effective August 15, 2026, UPMC for You and UPMC Community HealthChoices are moving multiple medications and medical supplies to nonpreferred status, requiring prior authorization for coverage. Affected items include specific oral medications (Belladonna Opium, Cevimeline, Dicyclomine, Klor-con M15, Potassium CL ER), bowel prep solutions (Generic Suprep), and most pen needles and lancets except for specified preferred brands (Techlite, Assure ID, Trueplus, and Accu-Chek products).
Action Required
By August 15, 2026: Billing team must implement prior authorization requirements in the billing system for all nonpreferred medications and supplies listed in this policy (Belladonna Opium Suppository, Cevimeline Capsule, Cyclomydril Eye Drops, Dicyclomine Oral Solution, Klor-con M15 Tablet, Potassium CL ER 15 MEQ Tablet, Generic Suprep, all pen needles except Techlite/Assure ID/Trueplus brands, and all lancets except Trueplus/Accu-Chek/Trividia brands). Update the billing software to flag these items and require prior authorization submission before processing claims. Notify providers and clinical staff to obtain prior authorization from UPMC before prescribing or dispensing these nonpreferred items. Update patient education materials to inform members that preferred alternatives may be available. Claims submitted without prior authorization for these nonpreferred drugs/products will be denied.