All Insurance Policy Changes (Page 130)

Continuing from page 129. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Gamifant (emapalumab-lzsg) prior authorization policy for Ohio Medicaid effective November 1, 2025, with a revision date of June 24, 2026. The policy establishes coverage criteria for two distinct indications: primary HLH requiring documented gene mutation or 5+ clinical characteristics plus failed conventional therapy and stem cell transplant candidacy, and HLH/MAS in Still's disease requiring inadequate response to glucocorticoids or recurrent MAS. All approvals require concurrent dexamethasone administration and carry 6-month initial and renewal periods.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Humana Medicaid (Indiana) prior authorization policy for Gamifant® (emapalumab-lzsg), an intravenous monoclonal antibody for treating primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. The policy establishes strict criteria requiring documented genetic mutations or clinical HLH-2004 diagnostic criteria, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy for approval. Initial and renewal approvals are limited to 6-month periods.
Medium impact
Gamifant® (emapalumab-lzsg) (Revised)
Humana·Effective Nov 1, 2025
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Gamifant® (emapalumab-lzsg) effective November 1, 2025, with revisions dated June 24, 2026. The policy establishes specific criteria for coverage of this IFN-gamma neutralizing antibody for primary hemophagocytic lymphohistiocytosis (HLH) and HLH/macrophage activation syndrome (MAS) in Still's disease. All Gamifant prescriptions require prior authorization with documented evidence of HLH diagnosis, failure of conventional therapy, concurrent dexamethasone use, and stem cell transplant candidacy.
Medium impact
Leqvio® (inclisiran) (Revised)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has revised its prior authorization policy for Leqvio® (inclisiran) effective July 1, 2026. The policy clarifies coverage criteria for hypercholesterolemia and heterozygous familial hypercholesterolemia (HeFH) patients aged 18+, requiring adjunctive therapy to maximally tolerated statins or documentation of statin-associated muscle symptoms (SAMs). A separate pathway covers pediatric homozygous familial hypercholesterolemia (HoFH) patients aged 12+. All Leqvio prescriptions now require prior authorization before dispensing.
Medium impact
Kineret (anakinra) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Kineret (anakinra) prior authorization policy effective January 1, 2026, with updates as of June 24, 2026. For rheumatoid arthritis patients, the policy now requires prior authorization with specific criteria: diagnosis of moderately to severely active RA, age 18+, and documented previous treatment failure or intolerance to at least two of three preferred agents (adalimumab products, Enbrel, or Rinvoq). The policy maintains coverage for CAPS (NOMID) and DIRA indications with separate authorization criteria.
Medium impact
Kevzara (sarilumab) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Kevzara (sarilumab) effective January 1, 2026, with updates as of June 24, 2026. The policy establishes specific clinical criteria for coverage across three indications: moderate to severe rheumatoid arthritis (requires 2 prior therapy failures/contraindications), polymyalgia rheumatica (requires 1 prior corticosteroid therapy/contraindication), and polyarticular juvenile idiopathic arthritis in patients ≥63 kg (requires 2 prior therapy failures/contraindications). All Kevzara requests require prior authorization before dispensing.
Medium impact
Fosaprepitant products (Emend, Focinvez) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for fosaprepitant products (Emend, Focinvez) effective January 1, 2026, with a revision date of June 24, 2026. Coverage requires the medication be used for prophylaxis (not treatment) of chemotherapy-induced nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy, AND must be part of a regimen that includes both a corticosteroid and a 5-HT3 antagonist, or the patient must have a contraindication to one of these drug classes. Prior authorization is required before dispensing.
Medium impact
Deferasirox Products (Revised)
Humana·Effective Jan 1, 2026
Humana has updated its Deferasirox Products prior authorization policy effective January 1, 2026, with a revision date of June 24, 2026. This policy establishes mandatory prior authorization requirements for all deferasirox products (Jadenu, Exjade, and generic formulations) for Medicare Advantage members with chronic iron overload. The policy defines specific clinical criteria for two indications: transfusional iron overload (ferritin >1000 mcg/L initially, >500 mcg/L for renewal) and non-transfusion dependent thalassemia syndromes (liver iron concentration ≥5 mg/gm initially, ≥3 mg/gm for renewal), with absolute contraindications including platelet counts <50,000/microliter and eGFR <40 mL/min/1.73m².
Medium impact
Bimzelx (bimekizumab-bkzx) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for Bimzelx (bimekizumab-bkzx), effective January 1, 2026, with a June 24, 2026 revision. The policy establishes specific prior authorization criteria for five approved indications: plaque psoriasis, psoriatic arthritis, non-radiographic axial spondyloarthritis, ankylosing spondylitis, and hidradenitis suppurativa. All requests require prior auth, with varying pre-treatment requirements (typically 2 prior failed therapies) depending on the diagnosis.
Medium impact
Akynzeo (fosnetupitant-palonosetron/netupitant- palonosetron) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage revised its Akynzeo (fosnetupitant-palonosetron/netupitant-palonosetron) prior authorization policy effective January 1, 2026, with updates as of June 24, 2026. For oral capsules, prior authorization now requires documented failure, contraindication, or significant side effects with aprepitant before Akynzeo approval. Both oral and IV formulations require use with highly emetogenic or moderately emetogenic chemotherapy. This is a revised policy that supersedes any previous Akynzeo guidance.
Medium impact
Hyrnuo (sevabertinib)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage now requires prior authorization for Hyrnuo (sevabertinib) when treating locally advanced or metastatic non-squamous NSCLC with HER2 TKD activating mutations in patients who have received prior systemic therapy. The medication must be prescribed as monotherapy to qualify for coverage. This is a new pharmacy policy effective February 25, 2026.
Medium impact
Exdensur™ (depemokimab-ulaa) (Revised)
Humana·Effective Jul 1, 2026
Humana revised its prior authorization policy for Exdensur™ (depemokimab-ulaa) effective July 1, 2026, covering Medicare Part D, Medicare Part B, and Medicaid (Kentucky and South Carolina). For Medicaid requests, the policy requires members to have severe asthma with eosinophilic phenotype (≥150 cells/μL at initiation or ≥300 cells/μL in prior 12 months) and failed adequate control on maximum tolerated inhaled corticosteroid plus long-acting beta agonist therapy. Prior authorization is mandatory before dispensing.
Low impact
LAMZEDE® (velmanase alfa-tycv) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Ohio has established a new prior authorization policy for LAMZEDE® (velmanase alfa-tycv) effective July 1, 2026. This enzyme replacement therapy for non-central nervous system manifestations of alpha-mannosidosis now requires prior authorization. Billing teams must implement prior auth requirements for intravenous LAMZEDE administration to avoid claim denials.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid-Indiana has established a new Prior Authorization policy for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager for treating extensive-stage small cell lung cancer (ES-SCLC) with disease progression after platinum-based chemotherapy. All Imdelltra claims require prior authorization effective July 1, 2026, and approval is contingent on meeting specific clinical criteria and avoiding exclusions related to disease progression while on therapy.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Louisiana Medicaid has implemented a new prior authorization policy for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager for extensive-stage small cell lung cancer. Coverage requires patients to have ES-SCLC with disease progression after platinum-based chemotherapy, with denial of approval if disease progression occurs while on Imdelltra. Prior authorization is mandatory before dispensing.
Medium impact
Imdelltra (tarlatamab-dlle) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization requirement for Imdelltra (tarlatamab-dlle), a bispecific T-cell engager indicated for extensive-stage small cell lung cancer with disease progression after platinum-based chemotherapy. Coverage requires prior auth approval for initial and renewal periods, with specific clinical criteria and exclusions based on treatment history and disease response.
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Identified Jul 1, 2026
Failed to analyze policy change
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid (Indiana) has established a new prior authorization policy for Exdensur™ (depemokimab-ulaa), an IL-5 antagonist for severe asthma with eosinophilic phenotype. Billing teams must implement prior authorization requirements before July 1, 2026, and ensure all three clinical criteria are documented before claim submission.
Medium impact
Exdensur™ (depemokimab-ulaa) (New)
Humana·Effective Jul 1, 2026
Humana Louisiana Medicaid is implementing a new prior authorization policy for Exdensur™ (depemokimab-ulaa), a biologic treatment for severe eosinophilic asthma. This is a NEW policy effective July 1, 2026, requiring prior authorization before dispensing. Billing teams must verify three clinical criteria (severe asthma diagnosis, elevated eosinophil levels ≥150 cells/μL or ≥300 cells/μL in past 12 months, and inadequate control on maximum inhaled corticosteroids with LABA) are met before submitting claims.
Medium impact
Cimerli® (ranibizumab-eqrn) (New)
Humana·Identified Jul 1, 2026
Humana Medicare Advantage has implemented a new Prior Authorization policy for Cimerli® (ranibizumab-eqrn), a ranibizumab biosimilar used for retinal conditions. Billing teams must obtain prior authorization before administering this drug to Medicare Advantage members to avoid claim denials.
Medium impact
Adcetris® (brentuximab vedotin) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Indiana has implemented a new prior authorization policy for Adcetris (brentuximab vedotin) effective July 1, 2026. This policy requires prior auth approval for seven distinct lymphoma indications with specific clinical criteria, approval durations of 6 months initially and at renewal, and explicit exclusions for patients experiencing disease progression on the drug.
Medium impact
Adcetris® (brentuximab vedotin) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Louisiana has implemented a new pharmacy prior authorization policy for Adcetris® (brentuximab vedotin) effective July 1, 2026. This policy establishes specific clinical criteria for coverage across seven indications including Hodgkin lymphoma, large B-cell lymphoma, and T-cell lymphomas. All Adcetris prescriptions require prior authorization with approval durations of 6 months or as clinically determined.
High impact
Adcetris® (brentuximab vedotin) (New)
Humana·Effective Jul 1, 2026
Humana Medicaid Ohio has implemented a new prior authorization policy for Adcetris (brentuximab vedotin) effective July 1, 2026. The policy covers seven distinct indications for Hodgkin lymphoma, large B-cell lymphoma, anaplastic large cell lymphoma, and mycosis fungoides, each with specific clinical criteria and approval durations of 6 months. Billing teams must implement prior authorization requirements before this effective date and ensure all seven indication pathways are correctly mapped in authorization systems.
High impact
Concurrent Delivery of Child and Adolescent Day Treatment and Residential Treatment Services
NC Medicaid - NCDHHS·Identified Jul 1, 2026
NC Medicaid clarified that Child and Adolescent Day Treatment services cannot be billed concurrently with Residential Treatment Services (Level II Program Type–IV) and seven other service types, except when medically necessary under EPSDT. Providers must now submit enhanced documentation justifying medical necessity, distinct therapeutic roles, and non-duplication for any concurrent service requests to be considered for approval.
Low impact
Virtual Institute: Bridging the Gap: Foundations of Integrated Care CME Courses Available
UPMC Health Plan·Effective Jul 8, 2026
UPMC is offering free CME educational webinars on integrated care topics (lifestyle medicine, sleep disorders, psychiatric medical mimics, and adolescent nicotine addiction) with continuing education credits for multiple healthcare professions. This is an informational announcement about professional development opportunities, not a billing or coverage policy change.

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Archive by year

2023 2024 2025 2026

Gamifant® (emapalumab-lzsg) (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Gamifant® (emapalumab-lzsg) (Revised)

Leqvio® (inclisiran) (Revised)

Kineret (anakinra) (Revised)

Kevzara (sarilumab) (Revised)

Fosaprepitant products (Emend, Focinvez) (Revised)

Deferasirox Products (Revised)

Bimzelx (bimekizumab-bkzx) (Revised)

Akynzeo (fosnetupitant-palonosetron/netupitant- palonosetron) (Revised)

Hyrnuo (sevabertinib)

Exdensur™ (depemokimab-ulaa) (Revised)

LAMZEDE® (velmanase alfa-tycv) (New)

Imdelltra (tarlatamab-dlle) (New)

Imdelltra (tarlatamab-dlle) (New)

Imdelltra (tarlatamab-dlle) (New)

Exdensur™ (depemokimab-ulaa) (New)

Exdensur™ (depemokimab-ulaa) (New)

Exdensur™ (depemokimab-ulaa) (New)

Cimerli® (ranibizumab-eqrn) (New)

Adcetris® (brentuximab vedotin) (New)

Adcetris® (brentuximab vedotin) (New)

Adcetris® (brentuximab vedotin) (New)

Concurrent Delivery of Child and Adolescent Day Treatment and Residential Treatment Services

Virtual Institute: Bridging the Gap: Foundations of Integrated Care CME Courses Available