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Upcoming Changes to Pharmacy Policies (PDF)
Effective date
Nov 1, 2026
Identified
Aug 26, 2026
Summary
This is the PDF copy of Ambetter's pharmacy criteria update, with the same content as the other Ambetter copy: prior authorization criteria for many medications change effective November 1, 2026, including the addition of HCPCS code Q5164. Changes include pediatric age extensions, new indications, redirections to generic or preferred products, the ICHRA line of business, and some tighter criteria. Because November 1, 2026 has already passed, these criteria are already in effect.
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What to do
Action · 5 steps
01Already effective November 1, 2026: Billing team and prior authorization staff: update the criteria checklist for affected medications before submitting requests.
02Key points: Simponi, Simponi Aria, Immgolis and Immgolis Intri for rheumatoid arthritis now need concomitant methotrexate or another DMARD; brand Xeljanz and Xeljanz XR requests are redirected to generic tofacitinib; Tofidence has a new CRS indication; Stelara and ustekinumab, Skyrizi and Taltz have pediatric changes; Tepezza and Lumvoa may not be prescribed together; and several hemophilia and other drugs now list the ICHRA line of business.
03Add HCPCS code Q5164 to your biosimilar tracking list.
04Providers ordering these drugs: confirm the new criteria before requesting authorization.
05The pre-emptive policies listed (such as Brepocitnib and Cemdisiran) have no criteria yet and need no action.
Codes mentioned
Q5164
Original notice
Upcoming Changes to Pharmacy Policies (PDF)
ambetterhealth.com · Always check the source before changing claims.