CommercialCoverageHigh impact
Effective September 1, 2026: Pharmacy and Biopharmacy Policies
Ambetter·MS · Oncology, Hematology, Pharmacy +3 more·Pharmacy
Effective date
Sep 1, 2026
We identified it
Sep 3, 2026
Summary
Magnolia Health Plan updated 13 pharmacy and biopharmacy policies effective September 1, 2026, reflecting new FDA approvals, formulation changes, age criteria updates, and indication expansions for oncology drugs, immunotherapies, and other specialty medications. Billing teams must verify coverage criteria changes for affected drugs and update prior authorization requirements accordingly.
Action Required
By August 31, 2026: Billing and prior authorization teams must review all 13 updated pharmacy policies on Magnolia Health's Clinical and Payment Policies webpage (https://www.ambetterhealth.com/en/provider-resources/provider-news/eff-sept-2026-pharmacy-biopharmacy-policies/). Key actions: (1) Update prior authorization criteria for oncology drugs (Padcev, Trodelvy, Retevmo, Sarclisa, Welireg, Ibrance) to reflect new FDA-approved indications and age/weight criteria; (2) For Casgevy, implement new age criteria (down to 2 years) and weight requirement (≥12 kg for SCD); (3) For Factor VIII products, update age criteria: Wilate no longer requires age ≥6 for VWD prophylaxis, Wilate requires age ≥12 for hemophilia A, Humate-P requires age ≥18 for hemophilia A; (4) Update Bimzelx criteria to require generic tofacitinib/tofacitinib XR instead of brand Xeljanz; (5) Add Nuedexta generic redirection; (6) Verify Ibrance tablet formulation is now supported for soft tissue sarcoma; (7) Update system rules for ICHRA line of business additions (Casgevy, Exagamglogene autotemcel, Topical Immunomodulators, Nuedexta). Pharmacy Department contact: 1-866-912-6285, ext. 66409. Failure to implement updates by effective date will result in claim denials and prior authorization delays.