To support access to safe and affordable treatments for our members, and to ensure we’re aligning with federal regulations, we’re making some changes to our medical and pharmacy drug coverage.
Pharmacy drug coverage changes
- Fycompa®
- Fycompa will be removed from pharmacy drug coverage effective Apr. 1, 2026, for commercial and individual members. This change has a member impact of 4.
- Its generic, perampanel, remains on commercial and individual formularies but will move from Tier 4 to Tier 1 beginning Apr. 1, 2026.
- Tazverik®
- Effective immediately, Tazverik has been withdrawn from the market by the U.S. Food and Drug Administration (FDA) due to potential safety concerns.
Medical drug coverage changes
Botulinum toxin
- In February, the Centers for Medicare & Medicaid Services (CMS) updated the Medicare Local Coverage Determination (LCD) for all botulinum toxins(Botox, Xeomin, Dysport, Daxxify, Myobloc), which affects coverage, documentation and medical necessity requirements for all such products. Providers should review the updated LCD—and its accompanying billing and coding information—to ensure compliance when treating Medicare patients with a botulinum toxin. Adherence is essential to support appropriate patient care and avoid current or retrospective claim denials.
Site of service changes
- Site of service requirements will be added for Rybrevant® beginning Apr. 1, 2026 for commercial and individual members who are new to the medication. Members already approved for Rybrevant will not be impacted by this change.
You can access our Medical Drug Lists (MDL) and our Approved Drug Lists (ADL) on the Drug Information page.