Summary
Effective January 1, 2027, this NPF formulary update removes 60+ brand-name drugs from coverage, uptiers 3 medications to require generic alternatives, adds step therapy to Gemtesa, implements quantity limits on diabetic test strips/insulin pumps, and removes Viread from the Health Care Reform List. Billing teams must immediately identify affected patients, update prior authorization workflows, and prepare claims adjustments for the January 1 effective date.
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What to do
by Dec 15, 2026 · 8 steps
01Billing team must audit active patient medication lists in the EHR/billing system to identify any patients currently on the 60+ excluded medications (e.g., Januvia, Entresto, Saxenda, Revlimid, Xeljanz, Harvoni, Epclusa, Sovaldi, OxyContin, Avanafil, Captopril, Cimetidine, Horizant, Ketoprofen, and others listed).
02For each affected medication, verify whether the patient is mid-treatment (applies to Harvoni, Epclusa, Sovaldi—which allow continuation) or requires immediate switching.
03Update billing software to flag claims containing excluded medications and automatically require generic/alternative substitution codes.
04Add Gemtesa step therapy requirement: system must validate that patients have failed at least two of the listed anticholinergics (darifenacin ER, fesoterodine ER, oxybutynin IR/ER, solifenacin, tolterodine IR/ER, trospium IR/ER, mirabegron) before approving coverage.
05Implement quantity limits in billing system: diabetic test strips (100/month without insulin, 300/month with insulin), Omnipod (10 pods/month), PEG-based bowel prep (2 kits/year), Twist refill kits (1/month).
06Notify providers of Viread removal from HCR list and update encounter templates to inform patients of increased cost-share effective January 1, 2027.
07Prepare denial/appeal response templates for claims submitted on or after January 1, 2027 containing excluded medications.
08Claims will be denied automatically unless prior authorization for alternatives is obtained in advance.
Original notice
Pharmacy Updates
bluecrossvt.org · Always check the source before changing claims.