All Insurance Policy Changes (Page 11)

Continuing from page 10. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Low impact
Justice-Involved (JI) Reentry Initiative: New Course for Member Eligibility
Medi-Cal·Effective Aug 11, 2026
Medi-Cal has released a new mandatory microlearning course (J1309ML) for providers to learn how to verify member eligibility for Justice-Involved (JI) Reentry Initiative pre-release services using the Single Subscriber method. Providers must register through the Medi-Cal Learning Portal (MLP) to access this training. This is an educational/operational requirement, not a billing code or coverage change.
High impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Oct 15, 2026
This policy expands coverage and adds clinical criteria for two drugs: Auvelity now covers agitation associated with Alzheimer's disease (with PRN use prohibition and new prior authorization documentation requirements), and Dupixent expands Chronic Spontaneous Urticaria coverage to younger ages (≥2 years), adds allergic fungal rhinosinusitis coverage, and implements indication-specific prescriber specialty requirements across all covered indications.
Medium impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross Medicare Advantage PPO plans in California will require prior authorization for five new procedure and supply codes: prostate cancer biochemical testing (0591U), genicular nerve destruction (64624), electronic transanal irrigation systems (A4479), digital cognitive therapy (A9294), and microprocessor-controlled ankle orthosis additions (L2221). Claims submitted without prior authorization may be denied as ineligible for payment.
Medium impact
[New York] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Medicare Advantage plans in New York will require prior authorization for 8 new procedure and supply codes, including prostate cancer screening (0591U), hematopoietic cell transplant preparation (38207-38209), genicular nerve destruction (64624), transanal irrigation systems (A4479), digital therapy (A9294), and lower extremity orthotic components (L2221). Billing teams must obtain precertification before providing these services to FIDE plan members or claims will be denied.
High impact
[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Nov 15, 2026
Carelon Medical Benefits Management has updated clinical appropriateness guidelines effective November 15, 2026, with significant changes to vascular procedures, genetic/molecular testing criteria, and cancer treatment indications. Key changes include expanded indications for varicose vein treatments, new drug eligibility for cancer molecular testing (imlunestrant, niraparib, talazoparib), broader genetic testing requirements across multiple cancer types, and removal of certain age/stage restrictions. Billing teams must review each clinical area for prior authorization and medical necessity documentation changes.
High impact
[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Nov 15, 2026
Carelon Medical Benefits Management has updated clinical appropriateness guidelines effective November 15, 2026, affecting vascular procedures, oncology genetic testing, and cardiology interventions. Key changes include new coverage criteria for inframalleolar angioplasty, varicose vein treatments, liver malignancy embolization, PFO closure age restrictions, and expanded genetic testing indications across multiple cancer types. These updates may require prior authorization workflow adjustments and documentation requirement changes for affected procedures.
Medium impact
[Ohio] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is adding five new codes to its precertification/prior authorization requirements. Providers must obtain prior authorization before delivering services under codes 0591U, 64624, A4479, A9294, and L2221, or claims may be denied as ineligible for payment. This change applies only to Anthem Medicare Advantage members in Ohio.
Medium impact
[Virginia] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia will require prior authorization for five new service codes: prostate cancer biochemical testing (0591U), genicular nerve destruction (64624), electronic transanal irrigation system (A4479), digital cognitive therapy (A9294), and microprocessor-controlled ankle orthosis (L2221). Claims submitted without prior authorization may be denied as ineligible for payment.
High impact
[Virginia] Quarterly pharmacy formulary change notice — Cardinal Care Medicaid
Anthem BCBS·Effective Aug 1, 2026
Anthem HealthKeepers Plus (Cardinal Care Medicaid) in Virginia is implementing significant pharmacy formulary and utilization management changes effective August 1, 2026. Multiple medications are moving to preferred status, being added to formulary, or having prior authorization and quantity limit edits added, removed, or modified. Billing teams must identify affected prescriptions, update prior authorization workflows, and communicate transition requirements to providers and patients.
High impact
[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines
Anthem BCBS·Effective Nov 15, 2026
Carelon Medical Benefits Management updated clinical appropriateness guidelines effective November 15, 2026, with major changes to vascular procedures (adding new ablation modalities, revising criteria for embolization), PFO closure (age-based restrictions), and genetic/molecular testing for cancer (expanding indications for liquid biopsy, somatic tumor testing, and tissue-based molecular profiling across multiple cancer types). Billing teams must review affected procedure approvals and update documentation requirements for cancer-related genetic testing.
Medium impact
[Georgia] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage in Georgia is adding five new codes to their prior authorization/precertification requirement list: 0591U (prostate cancer biochemical analysis), 64624 (genicular nerve destruction), A4479 (electronic transanal irrigation system), A9294 (digital cognitive/behavioral therapy), and L2221 (microprocessor-controlled ankle orthosis). All claims for these services must obtain prior authorization before delivery or risk denial.
Medium impact
\u201cExempt\u201d and \u201cNutritionals\u201d Infant Formula Coverage
Nebraska Medicaid·Effective Aug 11, 2026
Nebraska Medicaid has expanded Provider Bulletin 26-05 to clarify coverage for both "exempt" and "nutritionals" infant formula as primary payer. These formulas must be prescribed by a physician, determined medically necessary, and billed using HCPCS codes B4100-B4162 through the DME fee schedule. Beneficiaries must exhaust their monthly Medicaid limit before accessing WIC benefits for these formulas.
High impact
Reminder: Hospital trauma services enhanced professional payments
Washington Apple Health·Identified Aug 12, 2026
Washington State HCA is reminding providers that enhanced professional payments for trauma services are available at 275% of the standard fee-for-service rate. To receive this enhanced payment, providers must add the ST (trauma) modifier to qualifying trauma procedure codes on claims. Adjustment requests to add the ST modifier retroactively must be submitted within 1 year of the original service date.
High impact
Reminder: US Family Health Plan transition
Harvard Pilgrim Health Care·Effective Jan 1, 2027
US Family Health Plan (USFHP) administrative operations are transitioning from Point2Health/Tufts Health Plan to Brighton Marine effective January 1, 2027. All providers must establish direct contracts with Brighton Marine and verify credentialing status before the transition. Claims for dates of service prior to January 1, 2027 will be processed through April 30, 2027; after that date, Signature Performance will handle all claims processing.
Medium impact
Folotyn® (pralatrexate) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Folotyn (pralatrexate) prior authorization policy effective November 26, 2025, for Medicare, Medicaid-Florida, and Medicaid-South Carolina. The policy maintains prior authorization requirements for relapsed or refractory peripheral T-cell lymphoma (PTCL) treatment and explicitly excludes members who have experienced disease progression while on Folotyn. Billing teams must ensure prior authorization is obtained before dispensing and verify member eligibility for this high-cost injectable chemotherapy.
Medium impact
Beleodaq® (belinostat) (Revised)
Humana·Effective Nov 26, 2025
This is a revised Humana prior authorization policy for Beleodaq (belinostat) for relapsed or refractory peripheral T-cell lymphoma (PTCL), updated November 26, 2025. The policy requires prior authorization for all new and renewal requests, with approval duration of 6 months. Key exclusions include patients with disease progression on Beleodaq and those on concomitant HDAC inhibitor therapy (Istodax, Zolinza, Folotyn).
Medium impact
Copiktra™ (duvelisib) (Revised)
Humana·Effective Dec 17, 2025
Humana updated its Copiktra (duvelisib) prior authorization policy for Medicare Advantage members with a revision effective December 17, 2025. The policy maintains three approval criteria for relapsed/refractory CLL/SLL treatment as monotherapy and includes a critical exclusion: members with prior disease progression on any PI3K inhibitor (idelalisib, copanlisib, or duvelisib) are ineligible. The policy emphasizes black box warnings for treatment-related mortality, infections, diarrhea/colitis, cutaneous reactions, and pneumonitis.
Medium impact
Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)
Humana·Effective Jan 1, 2019
This is a revised Humana prior authorization policy for Erwinase (asparaginase Erwinia chrysanthemi) effective for Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina). The policy requires prior auth for ALL patients with acute lymphoblastic leukemia receiving Erwinase, with specific approval criteria including documented Grade 2-4 hypersensitivity to prior pegaspargase treatment and use as part of multi-agent chemotherapy. Four clinical exclusions apply: history of serious pancreatitis, thrombosis, hemorrhagic events, or disease progression on prior asparaginase therapy.
Low impact
Besponsa™ (inotuzumab ozogamicin) (Revised)
Humana·Effective Nov 26, 2025
Humana revised its Besponsa (inotuzumab ozogamicin) prior authorization policy effective November 26, 2025, for Medicare and Medicaid (Florida and Kentucky). The policy maintains requirements for B-cell precursor ALL with relapsed/refractory disease and CD22+ blasts, monotherapy use only, with approval limited to 6 months (maximum 6 cycles) per authorization period. This is a routine policy revision with no substantive changes to coverage criteria.
Low impact
Bavencio® (avelumab) (Revised)
Humana·Effective Jan 1, 2019
This is a routine revision (dated July 22, 2026) to Humana's Bavencio (avelumab) prior authorization policy for three Medicaid states (FL, KY, SC) plus Medicare. The policy maintains existing coverage criteria for four cancer indications: advanced/metastatic renal cell carcinoma (with axitinib), metastatic Merkel cell carcinoma (adults and pediatrics 12+), and locally advanced/metastatic urothelial cancer. No substantive coverage changes are documented—this appears to be a periodic policy refresh with updated prescribing information reference (June 2025) and clarification that progressive disease off-therapy does not meet exclusion criteria.
Medium impact
Gazyva® (obinutuzumab) (Revised)
Humana·Effective Jan 1, 2020
Humana has revised its Gazyva (obinutuzumab) prior authorization policy effective January 1, 2020, with the most recent update dated December 17, 2025. This pharmacy coverage policy applies to Medicare and three state Medicaid programs (Florida, Kentucky, South Carolina) and establishes prior authorization requirements for Gazyva use in chronic lymphocytic leukemia, follicular lymphoma, and lupus nephritis. Key criteria include specific combination therapy requirements, disease progression exclusions, and maintenance therapy duration limits that must be verified before claim processing.
High impact
Blincyto® (blinatumomab) (Revised)
Humana·Effective Jan 1, 2020
This is a revised Blincyto (blinatumomab) pharmacy coverage policy effective January 1, 2020, with the most recent revision dated July 22, 2026. The policy establishes prior authorization requirements for Blincyto use across four indications: relapsed/refractory B-cell ALL (Ph-negative and Ph-positive), B-cell precursor ALL with MRD, and B-cell precursor ALL in consolidation phase. The policy applies to Medicare and Medicaid (Kentucky and South Carolina) with specific clinical criteria that must be met for approval.
Medium impact
Calquence® (acalabrutinib) (Revised)
Humana·Effective Apr 22, 2026
Humana revised its Calquence (acalabrutinib) pharmacy coverage policy effective April 22, 2026. The policy maintains prior authorization requirements for two key indications: mantle cell lymphoma (with specific treatment pathway criteria) and chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Both indications exclude coverage if the member experiences disease progression while on or following Calquence. The policy requires verification of diagnosis, prior therapy history, and treatment combinations before approval.
Medium impact
Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)
Humana·Effective Jan 1, 2021
This is a revised Humana Medicare Advantage prior authorization policy for bexarotene products (Targretin and generic bexarotene capsules and topical gel) effective January 1, 2021, with a revision date of July 22, 2026. The policy requires prior authorization for bexarotene use in cutaneous T-cell lymphoma (CTCL), with specific criteria for systemic vs. topical formulations and mandatory exclusion for pregnant members. The revision reflects updated guidance on approval duration and documentation requirements.
Medium impact
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)
Humana·Effective Jul 22, 2026
Humana updated its Rylaze (asparaginase Erwinia chrysanthemi recombinant-rywn) prior authorization policy effective July 22, 2026, for Medicare and Medicaid members in Kentucky and South Carolina. This is a specialized oncology drug requiring prior authorization for ALL/LBL patients with documented Grade 2-4 hypersensitivity to prior asparaginase therapy. The policy maintains existing approval duration (6 months initial and renewal) and exclusion criteria for serious pancreatitis, thrombosis, hemorrhagic events, or disease progression.

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Archive by year

2023 2024 2025 2026

Justice-Involved (JI) Reentry Initiative: New Course for Member Eligibility

Drug Policy Criteria Change

[California] Precertification/prior authorization requirement changes

[New York] Precertification/prior authorization requirement changes

[New York] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Ohio] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Ohio] Precertification/prior authorization requirement changes

[Virginia] Precertification/prior authorization requirement changes

[Virginia] Quarterly pharmacy formulary change notice — Cardinal Care Medicaid

[Georgia] Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

[Georgia] Precertification/prior authorization requirement changes

\u201cExempt\u201d and \u201cNutritionals\u201d Infant Formula Coverage

Reminder: Hospital trauma services enhanced professional payments

Reminder: US Family Health Plan transition

Folotyn® (pralatrexate) (Revised)

Beleodaq® (belinostat) (Revised)

Copiktra™ (duvelisib) (Revised)

Erwinase® (asparaginase Erwinia chrysanthemi) (Revised)

Besponsa™ (inotuzumab ozogamicin) (Revised)

Bavencio® (avelumab) (Revised)

Gazyva® (obinutuzumab) (Revised)

Blincyto® (blinatumomab) (Revised)

Calquence® (acalabrutinib) (Revised)

Bexarotene products (Targretin capsules and gel, bexarotene capsules and gel) (Revised)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)