← Back to list
September 2026 Provider Notification
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 25, 2026
Summary
Ambetter from Arkansas Health & Wellness has implemented 24 policy amendments and retirements effective January 1, 2027, affecting pharmacy prior authorization, preferred drug designations, and coverage criteria across multiple lines of business (HIM, ICHRA, Commercial). Key changes include stricter GLP-1 agonist authorization requirements, removal of certain preferred drugs (Humatrope, Stelara), addition of generics with brand redirections, and updates to diabetes and specialty medication policies.
Get alerts when payers change rules like this one
We check Ambetter and other payers every day and email you when a change matches your specialty and state.
Get Ambetter alertsPolicy Monitoring is free. No card required.
What to do
by Dec 31, 2026 · 12 steps
01Billing and clinical teams must review and implement all 24 policy changes in Ambetter's pharmacy and prior authorization system.
02Update prior authorization software to change GLP-1 agonist requirements from 'failure of three' to 'failure of all' medications (policies HIM.PA.53, CP.PMN.295, CP.PMN.298).
03Remove prior auth requirements for Lantus, Toujeo, and unbranded Toujeo for Focused plans (HIM.PA.09); remove prior auth for Asmanex HFA, Asmanex Twisthaler, Tudorza Pressair, and Bevespi Aerosphere (HIM.PA.153).
04Update drug formulary to redirect to generics for Januvia, Janumet, Janumet XR (HIM.PA.58) and Farxiga, Xigduo XR (HIM.PA.91).
05Retire the following policies in system: HIM.PA.171 (Insulin detemir/Levemir), HIM.PA.178 (Immune Globulins), HIM.PA.87 (Testosterone/Androderm), CP.PCH.42 (Deutetrabenazine - replace with CP.CPA.370 and CP.PHAR.341).
06Remove Clindagel from appendix B for acne and isotretinoin policies (CP.PMN.143, HIM.PA.71, CP.PCH.32).
07Remove Humatrope from preferred drugs (HIM.PA.161) and redirect Acthar to Purified Cortrophin Gel for Focused plans (HIM.PA.168).
08Remove Stelara redirection and add Imuldosa as preferred for CD, PsO, PsA, UC (HIM.PA.SP60).
09For Focused plans, add redirections: Berotralstat to Haegarda (HIM.PA.169), Lanadelumab to Haegarda (HIM.PA.172), Awiqli to Lantus/Toujeo (HIM.PA.180).
10Remove Kisqali redirection for breast cancer palbociclib (HIM.PA.173).
11Add HIM/ICHRA lines of business to applicable policies and update Tennessee language for Immune Globulins (CP.PHAR.103); add Nebraska HIM bypass for PANDAS exclusion per state regulations.
12Create new Continuous Glucose Monitor policy (CP.PCH.64) adapted from CP.CPA.355 for HIM/ICHRA.
If missed: Failure to implement will result in claim denials, incorrect prior authorizations, and member access issues.
Original notice
September 2026 Provider Notification
ambetterhealth.com · Always check the source before changing claims.