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[Georgia] 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 Georgia will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. Practices must review affected patients before the effective date, transition them to covered alternatives where clinically appropriate, and submit prior authorization requests for any nonformulary medications that remain medically necessary.
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What to do
Action · 8 steps
01Before January 1, 2027.
02Billing team and providers: Review medication lists for all Medicare Advantage patients taking any of these drugs—Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva Handihaler, Spiriva Respimat, Stelara (unbranded), Xeljanz or Xeljanz XR, or Xigduo XR—enrolled in Anthem Blue Cross and Blue Shield Georgia Medicare Advantage plans.
03Providers: When clinically appropriate, discuss switching to the covered alternative listed in the payer's notice (e.g., ticagrelor for Brilinta, sitagliptin phosphate for Januvia, tiotropium or Spiriva Respimat for Spiriva Handihaler, dapagliflozin-metformin ER for Xigduo XR, tofacitinib ER for Xeljanz) and coordinate new prescriptions before January 1, 2027.
04Consider refill timing and any prior authorization requirements for the new medication.
05Providers: Use Real-Time Prescription Benefit (RTPB) when e-prescribing to confirm member-specific coverage, cost, and covered alternatives before sending prescriptions.
06For any nonformulary medication that remains medically necessary after the effective date: Submit electronic prior authorization through CarelonRx (https://carelonrx.com/solutions/providers > Prior authorization), by phone (833-377-4266), or by fax (844-521-6938).
07Claims without prior authorization will be denied.
08Document the clinical rationale and covered-alternative discussion in the patient record to support any subsequent prior authorization requests.
Original notice
[Georgia] 2027 Medicare formulary changes: Prepare now for
providernews.anthem.com · Always check the source before changing claims.