Centers for Medicare and Medicaid Services (CMS) has the Star Rating program which includes utilization of anticholinergic medication in patients age 65 or older. Starting Jan. 1, 2026, select Medicare Advantage members age 65 and older with overlapping anticholinergic therapies (14 days or more) may have anticholinergic medication claims denied at the pharmacy. Specific information (ex: hospice care, palliative care, etc.) may allow pharmacies to override the safety edit allowing the claim to process directly at point of sale however some instances may require a provider to submit a coverage determination (Prior Authorization) request for consideration of coverage.
Safety edits apply to single and combination products containing (not a complete list):
- Antidepressants* (e.g., paroxetine and tricyclic antidepressants)
- Antipsychotics* (e.g., chlorpromazine, olanzapine)
- Antiemetics
- Muscle relaxants
- Antispasmotics
- Antihistamines
- Antimuscarinics (for urinary incontinence)
- Antiparkinson medications (e.g., benztropine, trihexyphenidyl)
- Antiarrhythmic medication (disopyramide)
*Antidepressant and antipsychotic safety edits can be overridden by a dispensing pharmacist with prescriber approval or if the following applies: palliative care, hospice, cancer treatment, sickle cell disease.
Other drug classes will require a prior authorization (Medicare Coverage Determination) if there is concurrent use of two or more distinct medications. Prior authorization requests can be accepted for this 2026 safety edit starting Nov. 1, 2025. Please note the medication names and specify “2026 Poly-ACH safety DUR” rule on the form if the request is submitted before Jan. 1, 2026.
If you are notified that a patient age 65 or older will or may be impacted by this concurrent anticholinergic agent utilization edit, please closely review the case and look for opportunities to transition to alternative medications and/or therapies as clinically appropriate. If the benefits outweigh the risks, you may submit a Coverage Determination request form.
Additional resource: 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023; 71(7): 2052-2081. doi:10.1111/jgs.18372
