Medicare: Changes to non-formulary medication request process

Starting Jan. 1, 2026, any non-formulary medication request for patients who cannot be switched to a formulary alternative must include progress notes. To help avoid delays and potential denials, we strongly encourage prescribing formulary alternatives whenever possible.

Choosing a covered alternative helps:

• Accelerate access to treatment for your patients
• Reduce the risk of denials and appeals, saving time for your practice
• Improve adherence and outcomes by minimizing delays
• Avoid back-and-forth documentation requests, streamlining your workflow

To view covered alternatives, use PreCheckMyScript through most electronic medical records’ real-time benefit check functionality. You can also use the UnitedHealthcare Provider Portal with your One Healthcare ID. If you don’t have One Healthcare ID, register now.

If your patient can be switched to a formulary medication

If you need to cancel or withdraw the non-formulary request and send a new prescription for the formulary alternative to the pharmacy, please call 800-711-4555 or fax 844-403-1029.

If your patient can’t be switched to a formulary medication

To help us make accurate and efficient decisions, include documentation that supports the following:

• Medical records showing prior medications tried and failed, including formulary alternatives
• Clinical rationale for the requested medication, explaining why formulary alternatives are not appropriate for your patient
• Relevant clinical details, such as labs, progress notes and treatment history