OTC drug exclusion reminder and SGLT2 inhibitor update

By September 30, 2026: Billing team must (1) Update claim denial rules in billing software to reject claims for OTC drugs and OTC-equivalent prescriptions (antihistamines, H2 blockers, nasal steroids, fluoride, PPIs) for Harvard Pilgrim Health Care Commercial, Tufts Health Plan Commercial, and Tufts Health Direct members; (2) Configure system to allow exceptions only for pediatric formulations and ACA-mandated drugs. By November 14, 2026: (1) Update billing software rules for Commercial large group Premium/Value/Select formularies to automatically substitute generic dapagliflozin or dapagliflozin/metformin ER for brand SGLT2 inhibitors (Farxiga, Jardiance, Glyxambi, Synjardy, Synjardy XR, Trijardy XR, Xigduo XR); (2) Flag members currently on Farxiga or Xigduo XR for automatic pharmacy substitution (no provider action needed); (3) For members on other brand names, notify billing team that providers must submit new prescriptions for preferred generics or request prior authorization through medical review process; (4) Update claim denial rules to reject non-preferred brand SGLT2 claims without prior auth. Failure to implement these changes will result in claim denials and member coverage gaps.