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2027 Medicare Formulary Updates
Act
by Nov 16, 2026
Effective date
Jan 1, 2027
Identified
Oct 27, 2026
Summary
Highmark is updating its Medicare Part D formularies effective January 1, 2027, with medication removals and new restrictions. The Fundamental Formulary is being replaced with the Performance Formulary for all affected plans. Providers and members will receive notification letters starting mid-November 2026, and coverage determination requests can be submitted beginning November 16, 2026.
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What to do
by Nov 16, 2026 · 4 steps
01Billing and clinical teams should prepare to submit coverage determination requests for affected Medicare Part D medications using CoverMyMeds (via Availity Essentials) or the Prescription Drug Medication Request Form (available on Highmark's Provider Resource Center).
02Before January 1, 2027: Review the 2027 formularies on the Provider Resource Center's Medicare Formularies page to identify if patients' current medications are subject to removal or new restrictions.
03Upon receipt of member and provider notification letters (expected mid-November 2026 onward): For patients taking affected medications, coordinate with prescribers to either switch to covered formulary alternatives or initiate coverage determination requests.
04Note: West Virginia providers must use electronic submission only; faxing is not permitted.
If missed: Failure to proactively identify formulary changes may result in claim denials or medication access delays for Medicare Part D members.
Original notice
2027 Medicare Formulary Updates
providers.highmark.com · Always check the source before changing claims.