pharmacy benefits; prescribing; exemption

Patients keep approved drugs covered

For covered plans entered into, changed, extended, or renewed on or after December 31, 2025, previously approved drugs stay covered through the plan year while the patient remains enrolled. The prescriber must notify the plan in writing or electronically that the patient will continue the drug. Pharmacy benefit managers must give affected patients and prescribers at least 60 days’ notice before a change that limits or removes drug coverage. At renewal of the same plan, an exception must be approved for a previously approved nonformulary drug when the prescriber documents that it helped for more than 90 days, a formulary equivalent caused harm or was contraindicated, and alternatives pose a serious risk. Exception decisions are due within 72 hours after the request and relevant clinical records arrive, or within 24 hours for requested expedited review when urgent circumstances apply; denials need written reasons and appeal information, and approved exceptions last through the plan year. These rules apply to pharmacy benefit managers covered by state law, but not to disability policies providing limited-benefit coverage.