Medicare AdvantageCoverageMedium impact
Biosimilar Medication Formulary Updates
UPMC Health Plan·Pharmacy, Rheumatology, Nephrology +3 more·Pharmacy
Effective date
Sep 1, 2025
We identified it
Aug 7, 2026
Summary
UPMC Health Plan has updated formulary coverage for biosimilar medications (denosumab, eculizumab, and ustekinumab), effective on staggered dates between September and October 2025. Billing teams must verify formulary status and prior authorization requirements for these medications across multiple plan types and update internal systems accordingly.
Action Required
By August 15, 2025: Billing and clinical teams must review the September 2025 Provider Partner Update (pages 18-19) to identify specific formulary changes for denosumab, eculizumab, and ustekinumab biosimilars. Update billing system rules and prior authorization protocols for each medication by plan type (UPMC for Life: Sept 1-10, 2025; all others: Oct 1, 2025). Communicate formulary changes to providers and clinical staff to ensure accurate prescribing and reduce claim denials. Track effective dates separately by plan type in billing software. Failure to implement these changes may result in claim denials for non-formulary or improperly authorized biosimilar claims.