Medicare AdvantageCoverageHigh impact
2026 Medicare Advantage Formulary Updates
Highmark·PA, NY, WV, DE · Pharmacy·Pharmacy
Effective date
Jan 1, 2026
We identified it
Sep 5, 2026
Summary
Highmark is updating its Medicare Part D formularies effective January 1, 2026, with some medications being removed or having new restrictions. Providers and members will receive notification letters starting mid-November 2025. Billing teams must be prepared to handle formulary changes, submit coverage determination requests starting November 17, 2025, or identify covered alternatives for affected medications.
Action Required
By November 17, 2025: Billing and clinical teams must review the 2026 Medicare Part D formulary updates on the Provider Resource Center (PRC) by region to identify which medications are affected. Establish a process to: (1) check formulary status before submitting claims for Medicare Advantage members, (2) prepare to submit coverage determination requests via CoverMyMeds (accessible through Availity Essentials) or the Prescription Drug Medication Request form for affected medications, and (3) coordinate with prescribers to ensure they receive notification letters and are prepared to prescribe covered alternatives or request exceptions. Update billing workflows to flag Medicare Advantage claims for medications with formulary changes. Failure to address formulary changes will result in claim denials or member out-of-pocket costs.