All Insurance Policy Changes (Page 20)

Continuing from page 19. 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
PDL Update to Brand-name Focalin XR Capsules
Illinois Medicaid - HFS·Effective Jul 24, 2026
The manufacturer of brand-name Focalin XR (dexmethylphenidate extended-release) capsules has discontinued production. Illinois Medicaid has designated generic dexmethylphenidate ER capsules as preferred while continuing to list brand-name Focalin XR as preferred on the PDL until inventory is depleted. This change applies to both Fee-For-Service and Managed Care Organizations effective July 24, 2026.
Medium impact
PDL Update to Long-Acting Insulins
Illinois Medicaid - HFS·Effective Jul 24, 2026
Illinois Medicaid has temporarily moved insulin glargine-yfgn (a biosimilar) to preferred status on the PDL due to an intermittent supply shortage of Lantus SoloStar pens. This change applies to both Fee-For-Service and Managed Care Organization plans effective July 24, 2026. Lantus vials remain unaffected and preferred. The biosimilar preferred status is temporary and will be reversed once the shortage resolves.
High impact
26-959 Provider Communications Posted Online and Operations Manual Updates for July 2026
Health Net·Effective Jul 9, 2026
This is a July 2026 provider communications and operations manual update affecting Medi-Cal in Fresno, Kings, and Madera counties. Critical changes include: (1) Long-term care prior authorization requests must now be submitted by fax only (effective 7/9/26), (2) Encounter data submission requirements updated for quality measures compliance, and (3) Hospice care documentation and prior authorization requirements revised with a new Hospice Services Documentation Guide.
High impact
26-958 Provider Communications Posted Online and Operations Manual Updates for July 2026
Health Net·Effective Jul 24, 2026
This July 2026 policy update consolidates multiple operational changes across Medi-Cal including revised prior authorization submission methods for long-term care (fax only, no email effective 7/24/26), updated hospice documentation requirements and prior auth procedures (effective 7/21/26), new encounter data submission standards (QMED 2.0), maternity benefit clarifications, and drug formulary updates. Billing teams must implement these changes immediately to avoid claim denials and compliance issues.
High impact
26-956 Provider Communications Posted Online and Operations Manual Updates for July 2026
Health Net·Effective Jul 9, 2026
This July 2026 policy update consolidates multiple operational changes across Health Net California's provider manual, with the most critical change being that long-term care prior authorization requests for Medi-Cal must now be submitted by fax only (effective July 9, 2026) rather than email. Additionally, hospice prior authorization documentation requirements have been revised, encounter data submission requirements have been updated for Medi-Cal capitated providers, and maternity/perinatal services billing guidance has been clarified.
Low impact
Reminder: September 2026 Medi-Cal In-Person Training Event
Medi-Cal·Effective Sep 16, 2026
Medi-Cal is hosting a free in-person billing training event on September 16, 2026, in Modesto, California. The event includes updated course offerings with a new 'Navigating the Medi-Cal Website' course added and the 'CCS/GHPP' course removed. Providers must register by September 14, 2026, at 11:59 p.m. through the Medi-Cal Learning Portal.
Medium impact
Drug Policy Criteria Change
Arkansas Blue Cross Blue Shield·Effective Oct 1, 2026
Three drugs (Brinsupri, Hernexeos, and Modeyso) have new coverage criteria effective October 1, 2026. The policy document does not specify what the new criteria are, only that criteria have changed. Billing and clinical teams must obtain the detailed criteria from the payer to implement prior authorization or coverage requirements.
High impact
[California] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Blue Cross Medicare Advantage plans in California are adding prior authorization requirements for 30 specific procedure and supply codes, including prostate cancer screening (0591U), skin graft procedures (1044T-1049T, G0682, G0684), esophageal procedures (43192, 43201, 43210, 43236, 43497), neurolytic injections (64624), wound care matrices, neurostimulator generators, and orthotic devices. Claims submitted without prior authorization for these codes may be denied as ineligible for payment.
Medium impact
[Ohio] Precertification/prior authorization requirement changes
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield will require prior authorization for home health/hospice aide services (HCPCS code G0156) for all Fully Integrated Dual Eligible (FIDE) plans in Ohio. Claims submitted without prior authorization may be denied as ineligible for payment.
Medium impact
[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management
Anthem BCBS·Effective Dec 1, 2026
Effective December 1, 2026, Anthem Blue Cross and Blue Shield (including HealthKeepers, Inc.) in Virginia will require prior authorization through Carelon Medical Benefits Management for CPT code 1020T (Raman spectroscopy of skin lesions with malignant risk analysis). This applies to all PPO and HMO commercial plans in Virginia. Billing teams must update authorization workflows to route this procedure through Carelon before service delivery.
Medium impact
Reducing 30-day readmissions
Harvard Pilgrim Health Care·Identified Aug 7, 2026
Point32Health is emphasizing a quality initiative to reduce 30-day hospital readmissions through timely post-discharge follow-up and patient education, particularly focusing on transition of care (TOC) communication, medication reconciliation, and care coordination. This is a provider education policy rather than a billing rule change, but it may affect documentation and claim support for readmission prevention services.
Low impact
Tibsovo® (ivosidenib) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage updated its Tibsovo (ivosidenib) prior authorization policy on October 22, 2025, with no changes to coverage criteria or approval duration. This is a routine policy revision affecting IDH1-mutated AML, newly diagnosed AML, cholangiocarcinoma, and MDS. Billing teams should verify this is the current policy version before submitting prior authorization requests, as the document emphasizes online versions supersede printed copies.
Medium impact
Triptodur™ (triptorelin) (New)
Humana·Effective Aug 1, 2026
Humana Medicaid Ohio has established a new prior authorization policy for Triptodur (triptorelin) effective August 1, 2026, for treating central precocious puberty in pediatric patients 2 years and older. This is a pharmacy-level prior authorization requiring single criterion verification: confirmed diagnosis of central precocious puberty. All claims for this medication now require pre-approval before dispensing.
Medium impact
Transcatheter and Device-Based Hemodynamic Management Procedures - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage updated its policy on transcatheter and device-based hemodynamic management procedures effective 08/03/2026. The policy clarifies coverage criteria for implantable carotid sinus baroreflex activation therapy (BAT) for heart failure, requires enrollment in approved IDE studies or strict clinical criteria including LVEF ≤35% and specific biomarker thresholds, and references CMS National Coverage Determinations for pulmonary artery pressure sensors and renal denervation procedures. All services must meet medical necessity standards and contraindication exclusions.
High impact
Superficial Radiation Therapy - Medicare Advantage (Revised)
Humana·Effective Aug 3, 2026
Humana Medicare Advantage has updated its Superficial Radiation Therapy (SRT) policy effective 08/03/2026, establishing coverage criteria for nonmelanoma skin cancer treatment and introducing four new CPT codes (77436, 77437, 77438, 77439) effective 01/01/2026. The policy covers SRT including electronic brachytherapy and image-guided SRT when medical necessity criteria from applicable Local Coverage Determinations are met, with coverage varying by Medicare Administrative Contractor jurisdiction.
Medium impact
Updated blood lead reference value for children
UPMC Health Plan·Effective Oct 28, 2021
The CDC has lowered the blood lead reference value (BLRV) for children from 5 µg/dL to 3.5 µg/dL, effective immediately. This means more children will be identified as having elevated lead levels requiring clinical attention, case management referrals, and environmental investigation. Billing teams should ensure providers are aware of the updated screening threshold and that referrals to UPMC Pediatric Care Management are processed correctly for appropriate case management billing.
Medium impact
Recall: Clobetasol
UPMC Health Plan·Effective Jan 1, 2022
Taro Pharmaceuticals has recalled one lot (AC13786, expiration 12/2022) of Clobetasol Propionate Ointment USP 0.05% in 60g tubes due to potential safety concerns. The billing team must identify and flag any claims associated with this specific lot and coordinate with providers to ensure affected patients are notified and alternative treatments are prescribed.
High impact
Medicare annual wellness visit (AWV) reimbursement rate change 2022
UPMC Health Plan·Effective Jan 1, 2022
UPMC Health Plan is increasing reimbursement rates for Medicare annual wellness visits effective January 1, 2022. G0438 will be reimbursed at $200 and G0439 at $175. Billing teams must ensure visits are coded as wellness-only with proper CMS-compliant documentation to avoid claim denials and audits.
Low impact
Webinar: Pediatric Dyslipidemias: Screening, Diagnosis, and Management in the Primary Care Setting (recorded live)
UPMC Health Plan·Identified Aug 7, 2026
This is an educational resource announcement (not a billing policy change) promoting a recorded webinar on pediatric dyslipidemia management offered by UPMC. The webinar provides CME credits and is available for provider registration/viewing. This does not impose new billing requirements, coverage restrictions, or coding changes for the practice.
Medium impact
Recall: Metformin ER
UPMC Health Plan·Identified Aug 7, 2026
Viona Pharmaceuticals Inc. has recalled 33 lots of Metformin Hydrochloride Extended-Release Tablets, USP, 750 mg due to impurity levels exceeding FDA standards. This is a product-level pharmaceutical recall that may affect patient medications and requires coordination with pharmacy and clinical teams to identify affected patients and ensure alternative medications are provided.
High impact
IMPORTANT UPDATE: Extending the current UPMC Health Plan utilization model for selected MSK, cardiology, and radiology codes
UPMC Health Plan·Identified Aug 7, 2026
UPMC Health Plan is extending a temporary prior authorization expediting process through March 1st for selected MSK, cardiology, and radiology procedures and imaging. Prior authorization requests will be auto-approved without clinical documentation review during this period, but requests must still be submitted with complete information to avoid manual review delays and claim denials.
High impact
COVID-19 vaccines; No cost share for members
UPMC Health Plan·Effective Jan 1, 2022
UPMC Health Plan confirms COVID-19 vaccines remain covered with zero cost share for all members across all plan types (Medicare Advantage, commercial, Medicaid, and marketplace). As of January 1, 2022, UPMC for Life (Medicare Advantage) vaccination claims must be billed to UPMC Health Plan instead of Medicare Fee-for-Service. This clarification ensures proper claim routing and eliminates patient cost sharing for vaccine administration and products.
Low impact
UPMC Health Plan recommends COVID-19 booster shots for all who are eligible
UPMC Health Plan·Identified Aug 7, 2026
UPMC Health Plan has issued guidance recommending COVID-19 booster shots for all eligible members ages 16 and older, with specific vaccine and timing requirements by age group. This is an informational policy update regarding coverage and medical recommendations for booster vaccination, not a billing code or reimbursement rate change.
High impact
Requirements under the No Surprises Act
UPMC Health Plan·Effective Jan 1, 2022
The No Surprises Act (NSA), effective January 1, 2022, establishes new requirements for provider directory accuracy and verification. Providers must submit directory information updates to UPMC Health Plan when terminating agreements or making material changes, and must participate in quarterly directory verification through LexisNexis to maintain incentive payment eligibility. Failure to verify quarterly will result in loss of incentive payments.
Medium impact
Recall: Nitroglycerin Spray
UPMC Health Plan·Effective Jan 1, 2022
Padagis US LLC has issued a recall for Nitroglycerin Lingual Spray due to a complaint that the product may not work correctly. This affects the acute relief and prevention of chest pain in coronary artery disease patients. The billing team must be aware that claims involving this recalled product may require alternative medication billing or documentation of product replacement.

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Archive by year

2023 2024 2025 2026

PDL Update to Brand-name Focalin XR Capsules

PDL Update to Long-Acting Insulins

26-959 Provider Communications Posted Online and Operations Manual Updates for July 2026

26-958 Provider Communications Posted Online and Operations Manual Updates for July 2026

26-956 Provider Communications Posted Online and Operations Manual Updates for July 2026

Reminder: September 2026 Medi-Cal In-Person Training Event

Drug Policy Criteria Change

[California] Precertification/prior authorization requirement changes

[Ohio] Precertification/prior authorization requirement changes

[Virginia] Precertification/prior authorization requirement updates — Carelon Medical Benefits Management

Reducing 30-day readmissions

Tibsovo® (ivosidenib) (Revised)

Triptodur™ (triptorelin) (New)

Transcatheter and Device-Based Hemodynamic Management Procedures - Medicare Advantage (Revised)

Superficial Radiation Therapy - Medicare Advantage (Revised)

Updated blood lead reference value for children

Recall: Clobetasol

Medicare annual wellness visit (AWV) reimbursement rate change 2022

Webinar: Pediatric Dyslipidemias: Screening, Diagnosis, and Management in the Primary Care Setting (recorded live)

Recall: Metformin ER

IMPORTANT UPDATE: Extending the current UPMC Health Plan utilization model for selected MSK, cardiology, and radiology codes

COVID-19 vaccines; No cost share for members

UPMC Health Plan recommends COVID-19 booster shots for all who are eligible

Requirements under the No Surprises Act

Recall: Nitroglycerin Spray