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Upcoming Changes to Pharmacy Policies (PDF)
Act
by Dec 15, 2026
Effective date
Jan 1, 2027
Identified
Sep 29, 2026
Summary
This pharmacy policy update effective 1/1/2027 makes extensive changes to medication coverage criteria across 25+ drugs, including preferred agent redirections (e.g., Stelara to Imuldosa for autoimmune conditions), updated GLP-1 step-through requirements, addition of new line-of-business coverage (HIM/ICHRA), and retirement of obsolete policies. The most clinically impactful changes affect GLP-1 receptor agonists, insulin products, DMARDs, and biologics used in endocrinology, rheumatology, oncology, and dermatology practices.
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What to do
by Dec 15, 2026 · 9 steps
01Billing and clinical teams must review and implement the following mandatory changes.
02Update prior authorization protocols for GLP-1 receptor agonists (Wegovy, Zepbound) and DPP-4 inhibitors to reflect new step-through criteria requiring failure of ALL preferred agents rather than three.
03Reconfigure billing system to enforce preferred agent redirections—specifically Imuldosa for CD/PsO/PsA/UC replacing Stelara, and Haegarda/Lantus/Toujeo redirections for applicable drugs.
04Update encounter forms and clinical decision support to remove Stelara as preferred and stop ordering Humatrope for growth hormone therapy.
05For Nebraska HIM members, update prior authorization rules to allow bypass of PANDAS exclusion per state regulations in Immune Globulins policy.
06Disable prior authorization requirements for Focused plan members for Asmanex HFA/Twisthaler, Tudorza Pressair, Bevespi Aerosphere, Lantus, and Toujeo.
07Update system to recognize HIM and ICHRA as eligible line-of-business categories for Asciminib, Deutetrabenazine, DPP-4 inhibitors, Immune Globulins, SGLT2 inhibitors, and Continuous Glucose Monitors.
08Remove Clindagel from all appendices (Aczone, Isotretinoin, Topical Acne policies).
09Retire obsolete policies HIM.PA.178, HIM.PA.171, HIM.PA.87, and CP.PCH.42 from system access.
If missed: Failure to implement will result in prior authorization denials, incorrect claim routing, and member access delays.
Original notice
Upcoming Changes to Pharmacy Policies (PDF)
ambetterhealth.com · Always check the source before changing claims.