Formulary Policy Updates

Before member plan year start dates (varies by plan; typically January 1, July 1, or October 1, 2025): (1) Billing team must remove prior authorization requirements from system rules for: Crexont, Neffy, Ohtuvayre, Rytelo, Sofdra, Vafseo, Vigafyde, Voranigo, and Zoryve 0.15% cream. (2) Update claims processing to flag Nemluvio as non-covered for Commercial, Marketplace, and Self-Funded plans—claims should be denied with communication to providers about coverage exclusion. (3) Pharmacy staff must be notified to update formulary references and counsel members on new generic alternatives (Prucalopride for Motegrity, Esomeprazole DR suspension for Nexium granules, etc.). (4) Review MVP Formularies and Provider FastFax Library for complete coverage details before plan year effective date. Failure to update prior auth removal may result in unnecessary authorizations and workflow delays; failure to process Nemluvio as excluded will result in claim denials on appeal.