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[New York] 2027 Medicare formulary changes: Prepare now for
Effective date
Jan 1, 2027
Identified
Nov 3, 2026
Summary
Beginning January 1, 2027, Anthem Medicare Advantage formulary changes will move 10 select medications to nonformulary status in New York. The practice should review Medicare patients taking these drugs (Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva Handihaler/Respimat, Stelara, Xeljanz XR, Xigduo XR) and transition them to covered alternatives before the effective date to prevent pharmacy claim rejections and treatment delays.
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What to do
Action · 6 steps
01Before January 1, 2027.
02Billing team and providers: Review medication lists for all Medicare Advantage patients taking Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva Handihaler, Spiriva Respimat, Stelara (unbranded), Xeljanz XR, or Xigduo XR.
03Providers: Use Real-Time Prescription Benefit (RTPB) in the EHR workflow to verify member-specific coverage and identify covered alternatives before sending prescriptions.
04Providers: When clinically appropriate, discuss covered alternatives with patients and coordinate new prescriptions before January 1, 2027.
05Providers and billing team: Consider refill timing and prior authorization requirements for affected medications to ensure continuity of therapy.
06Billing team: Be prepared to submit prior authorization requests for any remaining nonformulary medications; submit electronic prior authorization (ePA) through https://carelonrx.com/solutions/providers or by phone (833-377-4266) or fax (844-521-6938).
If missed: Failure to transition patients or obtain prior auth may result in pharmacy claims being rejected in January.
Original notice
[New York] 2027 Medicare formulary changes: Prepare now for
providernews.anthem.com · Always check the source before changing claims.