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Effective January 1, 2027: Pharmacy and Biopharmacy Policies
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Oct 23, 2026
Summary
Effective January 1, 2027, Superior HealthPlan and Ambetter plans are implementing comprehensive updates to 30+ pharmacy and biopharmacy policies, including new prior authorization criteria, preferred drug redirections, and line-of-business expansions across multiple medication classes (insulin, GLP-1 agonists, DMARDs, biologics, and others). Billing teams must verify which policies affect their patient population and update prior authorization workflows, formulary redirects, and claim processing rules to reflect the new medical necessity criteria and preferred agent requirements.
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What to do
by Dec 31, 2026 · 10 steps
01Billing and clinical teams must review all applicable pharmacy policies listed (CP.PCH.64, ICHRA.PA.01, ICHRA.PA.02, ICHRA.PA.03, CP.PCH.32, CP.PCH.51, CP.PHAR.103, CP.PHAR.168, CP.PHAR.341, CP.PHAR.396, CP.PHAR.485, CP.PMN.58, CP.PMN.143, CP.PMN.295, CP.PMN.298, HIM.PA.09, HIM.PA.53, HIM.PA.58, HIM.PA.71, HIM.PA.91, HIM.PA.161, HIM.PA.168, HIM.PA.169, HIM.PA.172, HIM.PA.173, HIM.PA.180, HIM.PA.SP60, CP.PHAR.565, CP.PCH.42, HIM.PA.87, HIM.PA.171, HIM.PA.178) for their plan products and patient populations.
02Update prior authorization software and clinical decision support rules to reflect changed criteria (e.g., GLP-1 agonists now require 'failure of all' vs. 'failure of three' agents for concurrent T2DM members; Stelara removed as non-preferred for CD/PsO/PsA/UC with redirection to Imuldosa).
03Verify which line-of-business expansions apply (HIM, ICHRA, Medicaid STAR variants, CHIP, Exchange).
04Update preferred drug lists and formulary redirects in billing systems.
05For California Exchange plans, ensure Propranolol (Hemangeol) uses CP.PMN.58 criteria.
06For Nebraska HIM line of business, configure system to allow PANDAS exclusion bypass per state regulations.
07Remove retired policies (CP.PCH.42, HIM.PA.87, HIM.PA.171, HIM.PA.178) from active workflows.
08Confirm current applicability of new ICHRA line-of-business policies.
09Contact Centene Pharmacy Services at 1-866-768-7147 for clarification.
10Claims processed without updated criteria may require correction or resubmission.
Original notice
Effective January 1, 2027: Pharmacy and Biopharmacy Policies
ambetterhealth.com · Always check the source before changing claims.