ExchangeCoverageHigh impact
Individual markets formulary update for January 1, 2022
Blue Cross Blue Shield of Rhode Island·RI·Physician
Effective date
Jan 1, 2022
We identified it
Jun 19, 2026
Summary
BCBS Rhode Island updated their individual market formulary effective January 1, 2022, excluding numerous drugs from coverage, moving many drugs to higher cost-sharing tiers, and adding prior authorization requirements for several medications including Xolair injections.
Action Required
By January 1, 2022: Billing team must update prior authorization workflows for Xolair injections (150MG/ML, 75/0.5, SOL 150MG) and Everolimus tablets. Update patient communication processes to inform about higher copayments for over 100 medications moving from Tier 1 to Tier 2, and from Tier 2 to Tier 4. Verify coverage before dispensing excluded medications and recommend generic alternatives where available. Claims for excluded drugs will be denied without prior coverage verification.