REQUIREMENTS:
By April 30, 2026: Billing and clinical teams must:
1. REVIEW AFFECTED MEDICATIONS: Cross-reference all current FAMIS patient prescriptions against the formulary changes listed in this notice. Focus on newly restricted medications requiring prior authorization (e.g., EXDENSUR, SUBVENITE, KEYTRUDA QLEX, KOSELUGO, HYRNUO, KOMZIFTI, POHERDY, SPEVIGO, PYZCHIVA, ZORYVE, ENBUMYST, OMVOH, SKYRIZI, TREMFYA, VOYXACT, WAYRILZ, ARMLUPEG, BONDLIDO, KYGEVVI, RHAPSIDO, EYDENZELT, GLASSIA, JASCAYD, and others).
2. TRANSITION PLANNING: For each affected patient on a restricted medication:
- Attempt to transition to a formulary alternative if clinically appropriate
- Document clinical rationale if alternative is not suitable
- Communicate with prescribing providers regarding preferred alternatives
3. PRIOR AUTHORIZATION SUBMISSIONS: For patients where formulary alternatives are not clinically appropriate:
- Submit prior authorization requests to Anthem HealthKeepers Plus Pharmacy Department (800-901-0020) BEFORE May 1, 2026
- Include clinical justification for continued use of non-formulary or restricted medications
- Obtain authorizations for medications with new quantity limits or prior authorization requirements
4. SYSTEM UPDATES: Billing software and EHR must be updated to:
- Flag prescriptions for medications with new prior authorization requirements
- Enforce new quantity limits at point of billing
- Track prior authorization status for restricted medications
5. PROVIDER COMMUNICATION: Clinical staff must notify prescribers of:
- Quantity limit changes (e.g., FAMOTIDINE, IVERMECTIN, ELIDUIS, ANZEMET, DESLORATADINE, REPATHA, INLURIYO, KOSELUGO)
- New prior authorization requirements
- Preferred alternatives available
6. VERIFY ONGOING COVERAGE: For medications with updated dosing (e.g., STELARA/ustekinumab biosimilars with body-weight-based vials), ensure prescriptions align with new dosing parameters effective May 1, 2026.
CONSEQUENCES OF INACTION: Claims for restricted medications submitted after May 1, 2026 without prior authorization will be denied. Patients may experience coverage gaps if transition planning and prior authorization are not completed before the effective date.