All Insurance Policy Changes (Page 172)

Continuing from page 171. 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
Crisis Stabilization for Children and Adolescents - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 1, 2023
Humana updated its Louisiana Medicaid Crisis Stabilization policy for children and adolescents, effective 01/01/2023 with recent language updates on 01/15/2025 for provisionally licensed LMHPs and final LDH approval on 03/31/2025. Billing teams must ensure claims do NOT include room and board costs (only other funding sources reimburse these), recognize that crisis stabilization cannot be billed simultaneously with respite care, and verify member eligibility through Humana Healthy Horizons Louisiana. The policy defines covered services as short-term intensive out-of-home stabilization with family contact, assessment, and consultation—excluding institutional mental disease settings.
Medium impact
Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 1, 2023
This is an annual review of Humana's Louisiana Medicaid policy for Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) services with no substantive changes to coverage criteria or billing requirements. The policy clarifies medical necessity standards, assessment tools (LOCUS for adults, CALOCUS for children), and prior authorization documentation requirements for mental health rehabilitation services.
Medium impact
Cochlear Implant - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 1, 2023
Humana has updated its Louisiana Medicaid cochlear implant coverage policy (effective 01/01/2023, reviewed 10/01/2024). The policy covers unilateral or bilateral cochlear implants for members under 21 years of age with severe-to-profound bilateral sensorineural hearing loss, requiring a multidisciplinary team evaluation (pediatric otolaryngologist/otologist, audiologist, speech-language pathologist) and comprehensive pre- and post-operative assessments. No substantive coverage changes occurred in the 9/26/2024 review—only minor grammatical updates and reference refreshes.
Medium impact
Carvykti™ (ciltacabtagene autoleucel) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Carvykti (ciltacabtagene autoleucel), a CAR-T cell therapy for relapsed or refractory multiple myeloma. The policy requires patients to meet five clinical criteria (diagnosis, relapsed/refractory disease, prior multi-line therapy, age ≥18, use with lymphodepleting chemotherapy) and excludes those with active hepatitis B/C, prior allogeneic transplant, or prior CAR-T therapy. Approval is limited to one lifetime dose with a 60-day authorization duration.
Medium impact
Brukinsa™ (zanubrutinib) (Revised)
Humana·Effective Apr 22, 2026
Humana Medicare Advantage updated its Brukinsa (zanubrutinib) prior authorization policy effective April 22, 2026. The policy clarifies coverage criteria across five lymphoid malignancies with specific requirements for prior therapy, monotherapy use, and combination therapy depending on indication. Key change: Follicular lymphoma now requires combination with obinutuzumab after 2+ prior lines; all indications exclude coverage if patient experienced disease progression on Brukinsa.
High impact
Breyanzi® (lisocabtagene maraleucel) (Revised)
Humana·Effective May 1, 2026
Humana Louisiana Medicaid revised its Breyanzi® (lisocabtagene maraleucel) prior authorization policy effective May 1, 2026, covering six hematologic malignancies (Large B-cell Lymphoma 3L/2L, CLL/SLL, Follicular Lymphoma, Mantle Cell Lymphoma, and Marginal Zone Lymphoma). The policy requires prior authorization for all indications with specific clinical criteria, mandatory lymphodepleting chemotherapy co-treatment, and a lifetime maximum of one dose. Key exclusions include prior CD-19 CAR-T therapy, active hepatitis B/C, HIV/AIDS, CNS lymphoma, and prior allogeneic transplant.
Medium impact
Beovu® (brolucizumab) (Revised)
Humana·Effective Jan 28, 2026
Humana Medicaid Louisiana revised its Beovu (brolucizumab) prior authorization policy effective January 28, 2026. The policy requires prior authorization for Beovu use in neovascular wet AMD and diabetic macular edema, with approval contingent on patient contraindication/intolerance to bevacizumab OR documented failure to respond clinically to prior bevacizumab therapy. Billing teams must implement prior authorization requirements in their workflow before submitting claims for this medication.
High impact
Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) (Revised)
Humana·Effective Jan 1, 2023
This revised Humana policy (effective January 1, 2023, revised February 25, 2026) establishes prior authorization requirements for bendamustine products across five covered indications: CLL, Multiple Myeloma, Hodgkin Lymphoma, Non-Hodgkin's Lymphoma, and Waldenström's Macroglobulinemia. The policy specifies strict clinical criteria for each indication and excludes members experiencing disease progression on bendamustine-containing regimens. All bendamustine prescriptions require prior authorization approval for plan year duration.
Medium impact
Auryxia® (ferric citrate) (Revised)
Humana·Effective Jan 1, 2023
Humana updated its Auryxia (ferric citrate) prior authorization policy for Medicare Advantage members with a revision date of February 28, 2024. The policy maintains strict prior auth requirements for hyperphosphatemia treatment in dialysis patients and clarifies that members must have failed or been intolerant to both calcium acetate AND sevelamer carbonate before approval. The policy also includes an exclusion for iron deficiency anemia treatment in non-dialysis CKD patients without additional approvable indications.
High impact
Angiotensin Blocking Agents (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage has revised its Angiotensin Blocking Agents pharmacy coverage policy (effective 1/1/2023, revised 7/23/2025) to implement step therapy requiring members to have prior treatment with at least two ACE inhibitors or ARBs before coverage approval for newer agents (Edarbi, Edarbyclor, Arbli, azilsartan, valsartan oral solution). This is a step therapy requirement that affects prior authorization processes for these medications.
Medium impact
Aflibercept Products (Eylea®, Eylea® HD, Pavblu™) (Revised)
Humana·Effective Mar 1, 2026
Humana Louisiana Medicaid updated its prior authorization policy for aflibercept products (Eylea, Eylea HD, Pavblu) effective March 1, 2026. The policy maintains step-therapy requirements for AMD, DME, DR, and RVO indications (requiring bevacizumab trial or documented contraindication/intolerance first), but clarifies exemptions for DME and DR when vision is 20/50 or worse. ROP coverage requires no prior step therapy. All approvals are granted for one plan year with renewal available.
High impact
Abraxane (nab-paclitaxel) (Revised)
Humana·Effective Nov 1, 2025
Humana revised its Abraxane (nab-paclitaxel) prior authorization policy for Louisiana Medicaid, effective November 1, 2025. This is a pharmacy coverage policy requiring prior authorization for nab-paclitaxel across six cancer indications (breast, melanoma, NSCLC squamous, NSCLC non-squamous, ovarian, and pancreatic). The policy specifies strict clinical criteria for approval, including disease stage/progression status and hypersensitivity documentation requirements. Billing teams must verify all Abraxane claims meet these criteria before submission to avoid denial.
High impact
Abraxane (nab-paclitaxel) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicaid (Ohio) prior authorization policy for Abraxane (nab-paclitaxel) effective January 1, 2023 with recent updates as of November 1, 2025. The policy specifies detailed prior authorization criteria across six cancer indications (breast, melanoma, NSCLC squamous, NSCLC non-squamous, ovarian, and pancreatic), with most approvals requiring documented hypersensitivity reactions to conventional paclitaxel/docetaxel or contraindications to standard premedication. Billing teams must verify all prior authorization requirements before dispensing and ensure claims include proper medical necessity documentation.
High impact
Abraxane (nab- paclitaxel) (Revised)
Humana·Effective Jan 1, 2023
This is a revised Abraxane (nab-paclitaxel) prior authorization policy effective January 1, 2023, with a revision date of September 24, 2025. The policy applies to Medicare, Florida Medicaid, Kentucky Medicaid, South Carolina Medicaid, and Virginia Medicaid. Key coverage criteria vary by cancer type (breast, melanoma, NSCLC, ovarian, pancreatic) and require prior authorization with specific clinical requirements such as prior therapy history, hypersensitivity documentation, or specific combination therapy protocols. Note: Florida Medicaid requests are exempt from step therapy requirements.
High impact
Abecma® (idecabtagene vicleucel) (Revised)
Humana·Effective May 1, 2026
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Abecma® (idecabtagene vicleucel), a CAR-T cell therapy for relapsed or refractory multiple myeloma. The policy requires prior authorization before dispensing, with approval limited to one dose per lifetime over a 60-day duration. Key clinical criteria include diagnosis confirmation, relapsed/refractory disease per IMWG standards, at least two prior lines of therapy (immunomodulatory agent, proteasome inhibitor, anti-CD38 monoclonal antibody), age ≥18 years, and concurrent lymphodepleting chemotherapy. Three exclusions apply: active hepatitis B/C, prior allogeneic transplant, or prior CAR-T therapy.
Medium impact
Rebyota™ (fecal microbiota, live-jslm) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage revised its prior authorization policy for Rebyota (fecal microbiota, live-jslm) effective November 26, 2025. The policy establishes six mandatory clinical criteria for coverage, including age 18+, positive C. difficile toxin test within 30 days, minimum 2 prior recurrent CDI episodes (3+ total episodes), completed antibiotic course, controlled current infection, and administration within 24-72 hours post-antibiotic. Prior authorization is required for all Rebyota enema claims.
Medium impact
Lytgobi (futibatinib) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage updated the Lytgobi (futibatinib) prior authorization policy effective May 27, 2026. The policy now requires prior authorization for futibatinib use in Medicare Advantage members with unresectable locally advanced or metastatic intrahepatic cholangiocarcinoma (iCCA) with FGFR2 gene fusions/rearrangements who have received prior treatment. Coverage is approved for 6 months initially and at renewal.
Medium impact
Rezlidhia (olutasidenib) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage updated its Rezlidhia (olutasidenib) pharmacy coverage policy on November 26, 2025. The policy requires prior authorization for this IDH1 inhibitor used to treat relapsed/refractory acute myeloid leukemia (AML). Coverage requires documented IDH1 mutation, monotherapy use, and approval for initial 6-month periods with 6-month renewals. Claims will be denied without meeting all four clinical criteria and absence of exclusions.
High impact
Assertive Community Treatment (ACT/FACT) - MEDICAID - LOUISIANA (New)
Humana·Effective May 26, 2023
Louisiana Medicaid has established a new clinical coverage policy (LA.CLI.023) for Assertive Community Treatment (ACT/FACT) services effective immediately. All ACT service requests now require prior authorization and must meet specific medical necessity criteria including diagnosis requirements, service needs, and functional impairment thresholds. Billing teams must implement prior authorization workflows and validate patient eligibility against defined target population criteria before processing claims.
Medium impact
Sunlenca (lenacapavir) (Revised)
Humana·Effective Feb 28, 2024
Humana has revised its prior authorization policy for Sunlenca (lenacapavir), a new HIV-1 capsid inhibitor for heavily treatment-experienced patients with multidrug-resistant HIV infection. The policy requires prior authorization and establishes four strict clinical criteria for coverage, including age ≥18, documented multidrug resistance across three antiretroviral drug classes, use of optimized background regimen, and viral load ≥400 copies/mL. This is a recently updated policy (revised February 28, 2024) affecting commercial plans, and billing teams must implement prior authorization workflows immediately.
Medium impact
Lunsumio® & Lunsumio Velo™ (mosunetuzumab-axgb) (Revised)
Humana·Effective Feb 25, 2026
Humana has revised its prior authorization policy for Lunsumio® and Lunsumio Velo™ (mosunetuzumab-axgb) effective February 25, 2026. The policy covers treatment of relapsed or refractory follicular lymphoma in adult patients who have received at least two prior lines of systemic therapy and will use the drug as monotherapy. Prior authorization is required, with initial and renewal approvals valid for 6 months. Claims will be denied if patients experience disease progression while on or after Lunsumio/Lunsumio Velo treatment.
Medium impact
Krazati (adagrasib) (Revised)
Humana·Effective Feb 25, 2026
Humana Medicare Advantage has revised its Krazati (adagrasib) prior authorization policy effective February 25, 2026. The policy covers this KRAS G12C inhibitor for two indications: (1) locally advanced/metastatic NSCLC as monotherapy after one prior therapy, and (2) locally advanced/metastatic colorectal cancer in combination with cetuximab after prior chemotherapy. Both indications require documented KRAS G12C mutation and prohibit use in patients who have progressed on prior KRAS G12C inhibitors. Prior authorization is required with initial and renewal approvals valid for 6 months each.
Medium impact
Continuity of Care (Revised)
Humana·Effective May 27, 2026
Humana Medicaid Louisiana updated its Continuity of Care policy (revised May 27, 2026) to clarify when utilization management overrides (step therapy, prior authorization, non-preferred edits) apply to patients newly enrolled or transitioning to the plan. Members stable on pre-existing medications within 90 days of eligibility start qualify for override, EXCEPT for select medications with off-label use potential, fraud/abuse risk, or non-preferred generics. Claims for off-label or off-evidence uses will be denied.
High impact
Crisis Stabilization for Adults - MEDICAID - LOUISIANA (New)
Humana·Effective Jan 29, 2025
Humana Louisiana Medicaid updated its Crisis Stabilization (CS) for Adults policy effective 01/29/2025 to include language for provisionally licensed LMHPs. CS is a short-term, bed-based crisis treatment service for adults 21+ at risk of hospitalization. Billing teams must ensure claims include proper concurrent review documentation post-24 hours, psychiatric evaluations by qualified providers, and care coordination records, or face retrospective denial and recoupment.
Medium impact
Multi-Systemic Therapy (MST) - MEDICAID - LOUISIANA (New)
Humana·Effective Apr 15, 2023
Humana has updated its Multi-Systemic Therapy (MST) coverage policy for Louisiana Medicaid (Humana Healthy Horizons). The policy, last reviewed on 3/10/2025, establishes medical necessity criteria for MST services for youth ages 12-17 at risk of out-of-home placement. The policy defines initial treatment eligibility, exclusion criteria, continuation requirements, and discharge criteria. Billing teams must ensure all MST service requests include proper prior authorization documentation (psychosocial assessment and case summary/treatment plan) and verify member eligibility against the specified clinical criteria.

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Archive by year

2023 2024 2025 2026

Crisis Stabilization for Children and Adolescents - MEDICAID - LOUISIANA (New)

Community Psychiatric Support and Treatment (CPST) and Psychosocial Rehabilitation (PSR) - MEDICAID - LOUISIANA (New)

Cochlear Implant - MEDICAID - LOUISIANA (New)

Carvykti™ (ciltacabtagene autoleucel) (Revised)

Brukinsa™ (zanubrutinib) (Revised)

Breyanzi® (lisocabtagene maraleucel) (Revised)

Beovu® (brolucizumab) (Revised)

Bendamustine products (Treanda, Bendeka, Belrapzo, Vivimusta) (Revised)

Auryxia® (ferric citrate) (Revised)

Angiotensin Blocking Agents (Revised)

Aflibercept Products (Eylea®, Eylea® HD, Pavblu™) (Revised)

Abraxane (nab-paclitaxel) (Revised)

Abraxane (nab-paclitaxel) (Revised)

Abraxane (nab- paclitaxel) (Revised)

Abecma® (idecabtagene vicleucel) (Revised)

Rebyota™ (fecal microbiota, live-jslm) (Revised)

Lytgobi (futibatinib) (Revised)

Rezlidhia (olutasidenib) (Revised)

Assertive Community Treatment (ACT/FACT) - MEDICAID - LOUISIANA (New)

Sunlenca (lenacapavir) (Revised)

Lunsumio® & Lunsumio Velo™ (mosunetuzumab-axgb) (Revised)

Krazati (adagrasib) (Revised)

Continuity of Care (Revised)

Crisis Stabilization for Adults - MEDICAID - LOUISIANA (New)

Multi-Systemic Therapy (MST) - MEDICAID - LOUISIANA (New)