All Insurance Policy Changes (Page 136)

Continuing from page 135. 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
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.
High impact
Fast Facts Newsletter - July 2026
HealthPartners·Effective Jul 1, 2026
This July 2026 HealthPartners Fast Facts newsletter contains multiple administrative and medical policy updates. Key changes include: (1) Medical policy updates effective 07/01/2026 and 08/01/2026 affecting dermatology, ophthalmology, oncology testing, investigational services, lipedema/lymphedema surgery, and balloon sinuplasty; (2) Enhanced online access to claim adjustment and appeal details via provider portal (live as of 06/09/2026); (3) New Technology Committee review of 30+ emerging medical technologies; (4) Requirements to update provider directory information and complete cultural competency/ADA accessibility questionnaire; (5) Administrative changes to Cohere Portal submission process and PointClickCare ADT Network.
Medium impact
DSS Important Message - Multi-Factor Authentication Mandated Enrollment on August 1,2026; Open Office Hours for Multi-Factor Authentication/Security Questions; Security Question Updates, Notifications
Connecticut Medicaid (HUSKY Health)·Effective Aug 1, 2026
The Connecticut Medical Assistance Program (CMAP) is mandating Multi-Factor Authentication (MFA) enrollment for all providers, trading partners, and drug labelers by August 1, 2026. MFA is currently optional but will become required for all portal logins, password changes, and EFT updates. Additionally, security question structures have been updated to use dropdown menus instead of free-form questions (effective May 13, 2026).
High impact
Medical Policy Update July 1, 2026
Blue Cross NC·Effective Jul 1, 2026
Blue Cross NC has updated 13 medical policies effective July 1, 2026, adding 50+ new PLA and CPT codes across genetic testing, advanced diagnostics, and specialized procedures. The billing team must update claim submission systems and encounter documentation to recognize these new codes to avoid claim denials and ensure proper reimbursement.
High impact
Maternal Mental Health Screening Requirements
L.A. Care Health Plan·Effective Jun 17, 2026
L.A. Care updated its Maternal Mental Health Screening Requirements policy (effective immediately) requiring providers to conduct and document validated depression screenings during pregnancy (first trimester recommended) and within 6 weeks postpartum, with positive results requiring follow-up within 30 days. Billing teams must now use specific LOINC codes and ensure depression follow-up encounters include billable CPT codes for proper claim submission and HEDIS measure reporting.
High impact
Maternal Mental Health Screening Requirements
L.A. Care Health Plan·Effective Jun 17, 2026
L.A. Care has updated its Maternal Mental Health Screening Requirements policy (effective immediately) to mandate documented depression screening during pregnancy (first trimester recommended) and within 6 weeks postpartum using validated tools (PHQ-2, PHQ-9, PHQ-A, EPDS), with specific LOINC codes and billing requirements for depression follow-up associated with billable CPT encounters. Positive screens require documented follow-up within 30 days and referral to Carelon Behavioral Health or LA County Department of Mental Health.
High impact
Maternal Mental Health Screening Requirements
L.A. Care Health Plan·Effective Jun 17, 2026
L.A. Care revised its Maternal Mental Health Screening Requirements (effective immediately) requiring providers to conduct and document maternal mental health screenings during pregnancy (first trimester recommended) and within 6 weeks postpartum using validated tools (EPDS, PHQ-2, PHQ-9, PHQ-A), with positive screens requiring documented follow-up within 30 days. Billing teams must now use specific LOINC codes and ensure screening documentation is linked to billable CPT codes for proper claims submission and HEDIS measure reporting.
High impact
Member eligibility response (271) changes coming Sept. 1
Priority Health·Effective Sep 1, 2026
Effective September 1, 2026, Priority Health will transition member eligibility response (271) data to Epic's X12 format, which displays more comprehensive benefit information. Key changes include: benefits now show all tier levels regardless of provider network status, $0 copays/coinsurance are implied (not displayed), and historical inactive benefits appear with flags. Billing teams must adjust interpretation workflows to match specific services to active benefits and verify eligibility carefully before estimating patient financial responsibility.
Low impact
Here’s your one-stop guide to provider communications
Priority Health·Effective Jun 30, 2026
Priority Health has published a comprehensive guide consolidating all provider communication channels and resources into a single reference document. This is an informational update directing billing teams and providers to use this guide to locate policy updates, training opportunities, and ongoing resources across multiple communication platforms (Provider Manual, PriorityActions emails, webinars, portal messages, newsletters, etc.).
Low impact
Clearing Cache Reminder
Blue Cross Blue Shield of Rhode Island·Effective Jul 1, 2026
BCBS Rhode Island has issued a reminder that system updates (particularly the authorization tool MHK) may require users to clear their browser cache, log out, and log back in to resolve errors. This is a technical support advisory for providers accessing BCBS systems, not a clinical or billing policy change.
High impact
Reminder to specialists – Reducing prior authorization requests
Blue Cross Blue Shield of Rhode Island·Effective Oct 1, 2025
Blue Cross Blue Shield Rhode Island is reminding specialists that they must use the provider portal tools to verify prior authorization requirements before submitting requests. Effective immediately, 53 CPT/HCPCS codes no longer require prior authorization across all lines of business, and as of October 1, 2025, fully insured commercial members require no prior authorization for any service. Specialists—not PCP offices—are responsible for determining authorization necessity.
Low impact
Join us for a call with the BCBSRI Provider Relations team
Blue Cross Blue Shield of Rhode Island·Effective Aug 11, 2026
BCBSRI is hosting a provider education conference call on August 11, 2026, from 10-11 a.m. to deliver important updates and reminders. This is an informational/administrative notification with no direct impact on billing codes, coverage, or reimbursement policies.
High impact
Prepayment change reminder
Blue Cross Blue Shield of Rhode Island·Effective Jul 1, 2024
BCBSRI has implemented enhanced prepayment claim reviews using Optum's Comprehensive Payment Integrity (CPI) tool starting July 2024. Providers must now be prepared to submit medical records and billing documentation on request to support billed charges. Claims will only be paid if documentation supports the services billed, and providers may face coding/payment adjustments or have the right to appeal.

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Archive by year

2023 2024 2025 2026

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

Fast Facts Newsletter - July 2026

DSS Important Message - Multi-Factor Authentication Mandated Enrollment on August 1,2026; Open Office Hours for Multi-Factor Authentication/Security Questions; Security Question Updates, Notifications

Medical Policy Update July 1, 2026

Maternal Mental Health Screening Requirements

Maternal Mental Health Screening Requirements

Maternal Mental Health Screening Requirements

Member eligibility response (271) changes coming Sept. 1

Here’s your one-stop guide to provider communications

Clearing Cache Reminder

Reminder to specialists – Reducing prior authorization requests

Join us for a call with the BCBSRI Provider Relations team

Prepayment change reminder