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[Ohio] 2027 Medicare formulary changes: Prepare now for
Effective date
Jan 1, 2027
Identified
Nov 3, 2026
Summary
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. The practice must review patient medication lists, coordinate therapy transitions to covered alternatives before the effective date, and submit pharmacy prior authorizations electronically to avoid claim denials and treatment delays in January.
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What to do
Action · 8 steps
01Before January 1, 2027.
02Billing and clinical staff review the medication lists of all Medicare Advantage patients currently taking Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva Handihaler, Spiriva Respimat, Stelara (unbranded), Xeljanz, Xeljanz XR, or Xigduo XR.
03Tell providers to discuss covered alternatives (listed in the source) with affected patients and coordinate new prescriptions before January 1, 2027 when clinically appropriate.
04When e-prescribing in the EHR, use Real-Time Prescription Benefit (RTPB) to confirm member-specific coverage, cost, and covered alternatives before sending prescriptions.
05Coordinate refill timing and confirm any prior authorization or utilization management requirements for the covered alternative before the effective date.
06For any medication that cannot be transitioned by January 1, 2027, prepare to submit pharmacy prior authorization requests electronically via CarelonRx (https://carelonrx.com/solutions/providers > Prior authorization), by phone at 833-377-4266, or by fax to 844-521-6938; ePA provides automatic response and is faster than phone or fax.
07Document all therapy reviews and transitions in the patient record.
08Inaction will result in rejected pharmacy claims, treatment delays, and coverage requests in January 2027.
Original notice
[Ohio] 2027 Medicare formulary changes: Prepare now for
providernews.anthem.com · Always check the source before changing claims.