2026 Updates

12/2025 Formulary updates effective Jan. 1, 2026

Please review updated information for the prescription drugs covered under each plan.

UPMC Health Plan Commercial Plans

UPMC for Life Medicare, SNP Plans

View UPMC for Life formulary updates:

Exception request options

Requests for exceptions can be submitted to Pharmacy Services by one of the following methods:

Questions?

Please contact your physician account executive or Pharmacy Services at 1-800-979-8762 if you have questions about any of these updates.

UPMC for Life (Medicare, Special Needs), UPMC Health Plan (Commercial, Exchange), and UPMC for Kids (CHIP) continuous glucose monitor (CGM) coverage updates

  • At UPMC Health Plan, we know that monitoring blood glucose levels is important for your patients with diabetes, and access to continuous glucose monitors (CGMs) and their corresponding supplies is necessary. For these reasons, we want to make you aware that coverage of certain CGMs and their corresponding supplies is changing soon.
  • On Jan. 1, 2026, Freestyle Libre and Dexcom CGM products will no longer be covered when dispensed by a durable medical equipment (DME) provider. These products must be dispensed by a network pharmacy to be covered.
    • Members using other CGMs (i.e., not Freestyle Libre or Dexcom) are not affected by this change and may continue to use their DME provider. DME providers must submit claims for CGMs with a valid NDC in order for these claims to process.
  • Members will likely need prescriptions for their Freestyle Libre and Dexcom CGM supplies sent to a network pharmacy. This can be done electronically so that our members can maintain access to the supplies they need without waiting for an in-person appointment.
  • Any member with a current, active authorization on file for a Freestyle Libre or Dexcom CGM product will not need an updated authorization to switch from their DME provider to a network pharmacy.
    • Otherwise, requests for prior authorization for members who are newly starting a CGM can be submitted to Pharmacy Services electronically through SureScripts ePA, through the online portal at Home – UPMC PromptPA Portal, or over the phone at 1-800-979-8762.
  • If you have any questions, feel free to call Pharmacy Services at 1-800-979-8762, Monday through Friday between 8 a.m. and 5 p.m.
  • We have notified members, their DME providers, and the providers who are treating diabetes of this change.

Hyaluronate intra-articular injections billing update for UPMC Health Plan (Commercial, Exchange) and UPMC for Kids (CHIP) lines of business

Effective Jan. 1, 2026, hyaluronate intra-articular injections will be able to be billed on either the pharmacy or medical benefit for the UPMC Health Plan (Commercial, Exchange), and UPMC for Kids (CHIP) lines of business. Prior to Jan. 1, 2026, they were only available for billing under the pharmacy benefit. The preferred products for the UPMC Health Plan (Commercial, Exchange) and UPMC for Kids (CHIP) lines of business will continue to be Euflexxa and Durolane. All other products will remain nonformulary/nonpreferred on both the pharmacy and medical benefits. Members may continue to fill their medication at Chartwell or Accredo.

Billing updates for UPMC Health Plan (Commercial, Exchange) and UPMC for Kids (CHIP) lines of business

Effective Jan. 1, 2026, select intravenous and subcutaneous products will be required to be billed through the medical benefit for the UPMC Health Plan (Commercial, Exchange) and UPMC for Kids (CHIP) lines of business. Any product that currently requires a prior authorization in 2025 will continue to do so 2026; however, any member with a current active authorization on file will not need an updated authorization. Please reference this grid for the affected medications. Members may still be able to continue to fill their medication(s) at Chartwell or Accredo.

Biosimilar formulary updates: Adalimumab preferred products

Effective Jan. 1, 2026, there will be changes to the preferred and nonpreferred adalimumab products for the UPMC for Life (Medicare, Special Needs), UPMC Health Plan (Commercial/Exchange), and UPMC for Kids (CHIP) formularies. Most notably the innovator drug, Humira, will be moving to a nonformulary status.

Effective Jan. 5, 2026, there will be changes to the preferred and nonpreferred adalimumab products for the UPMC for You and UPMC Community HealthChoices formularies, as required by the DHS statewide PDL.

The DHS statewide PDL, including coverage status for adalimumab products, may be accessed at the following link: Preferred Drug List (papdl.com). Please note that the coverage status of drugs included on the statewide PDL may be subject to change.

For full details on these changes, please refer to December 2025 edition of Provider Partner Update.