All Insurance Policy Changes (Page 36)

Continuing from page 35. 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
Levoleucovorin products (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Levoleucovorin products prior authorization policy (effective September 24, 2025) covering Medicare and three state Medicaid programs (Kentucky, South Carolina, Virginia). The policy maintains prior authorization requirements for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer with 5-fluorouracil. Key requirement: members must have documented side effects from leucovorin calcium (either lack of efficacy or formulation issues) to qualify for levoleucovorin substitution.
Medium impact
Idhifa® (enasidenib) (Revised)
Humana·Effective Oct 22, 2025
Humana has revised its prior authorization policy for Idhifa (enasidenib) effective October 22, 2025. The policy now covers two distinct AML indications: relapsed/refractory AML with IDH2 mutation and newly diagnosed AML in patients ineligible for intensive induction therapy. Both pathways require IDH2 mutation documentation and prior authorization with 6-month approval/renewal cycles. Key change: newly diagnosed AML coverage is now explicitly included, expanding eligible patient populations.
Medium impact
Jemperli (dostarlimab-gxly) (Revised)
Humana·Effective Sep 24, 2025
Humana revised its Jemperli (dostarlimab-gxly) prior authorization policy effective September 24, 2025, affecting coverage for endometrial cancer (frontline and 2nd line+) and dMMR solid tumors across Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains three distinct approval pathways with specific clinical criteria and adds explicit exclusions for patients with disease progression on prior anti-PD-1/PD-L1 therapy.
Medium impact
Rezurock (belumosudil) (Revised)
Humana·Effective Sep 24, 2025
Humana Medicare Advantage updated its Rezurock (belumosudil) prior authorization policy effective September 24, 2025. The policy maintains three approval criteria: cGVHD diagnosis, failure of at least two prior systemic therapy lines, and documented medical reason why Jakafi (Ruxolitinib) cannot be used. Claims will be denied if the member experiences disease progression while on Rezurock. Billing teams must ensure prior authorization is obtained before dispensing and document the required clinical criteria.
High impact
Levoleucovorin products (Revised)
Humana·Effective Jan 1, 2023
This is a revised Humana Medicaid Louisiana prior authorization policy for levoleucovorin products (Khapzory, Fusilev, and generics) effective January 1, 2023, with a revision dated September 24, 2025. The policy outlines coverage criteria for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer with 5-fluorouracil. Key requirement: prior authorization is mandatory, and coverage is only approved if the member has already failed or experienced side effects from standard leucovorin calcium therapy, necessitating a switch to levoleucovorin.
Medium impact
Rezlidhia (olutasidenib) (Revised)
Humana·Effective Nov 26, 2025
Humana Medicare Advantage revised its Rezlidhia (olutasidenib) prior authorization policy on November 26, 2025, for relapsed/refractory acute myeloid leukemia with documented IDH1 mutation. The policy requires prior authorization for monotherapy use, with initial 6-month approval and 6-month renewals. Key clinical requirements include ECOG performance score 0-2, black box warning for differentiation syndrome, and mandatory liver function monitoring.
Medium impact
Orserdu (elacestrant) (Revised)
Humana·Effective Oct 22, 2025
Humana Medicare Advantage updated its prior authorization policy for Orserdu (elacestrant) effective October 22, 2025. This is a pharmacy coverage policy requiring prior authorization for this selective estrogen receptor degrader used to treat ER-positive, HER2-negative, ESR1-mutated advanced or metastatic breast cancer. The policy requires confirmation of specific clinical criteria including documented ESR1-mutation status and prior endocrine therapy failure before approval. Initial and renewal approvals are for 6-month periods.
Medium impact
Levoleucovorin products (Revised)
Humana·Effective Jul 1, 2024
Humana Indiana Medicaid has revised its prior authorization policy for levoleucovorin products (Khapzory, Fusilev, and generic formulations) effective July 1, 2024, with the most recent revision dated September 24, 2025. The policy requires prior authorization for three indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdosage, and advanced metastatic colorectal cancer with 5-fluorouracil. All three indications now require documented evidence that the member has previously tried leucovorin calcium and experienced side effects due to either lack of efficacy or formulation issues necessitating a change to levoleucovorin.
Medium impact
Faslodex (fulvestrant) (Revised)
Humana·Effective Jan 1, 2025
Humana revised its Faslodex (fulvestrant) prior authorization policy effective January 1, 2025, with updates published September 24, 2025. The policy now covers fulvestrant as monotherapy for HR-positive, HER2-negative advanced breast cancer in treatment-naive or endocrine-resistant patients, and as combination therapy with CDK 4/6 inhibitors for initial or post-progression treatment. Prior authorization is required for all uses across Medicare, Kentucky Medicaid, and South Carolina Medicaid.
Medium impact
Alternate nilotinib products (Danziten, Cavhanza, nilotinib tartrate-Cipla) (Revised)
Humana·Effective Feb 26, 2025
Humana has established a prior authorization policy for three alternate nilotinib products (Danziten, Cavhanza, and nilotinib tartrate-Cipla) used to treat chronic myeloid leukemia in Medicare Advantage members. The policy requires prior authorization and applies only to members age 18+ with CML diagnosis, with an exclusion for members who have experienced disease progression on any nilotinib product.
Medium impact
Levoleucovorin products
Humana·Effective Sep 24, 2025
Humana Medicaid Ohio implemented a NEW prior authorization requirement for levoleucovorin products (Khapzory, Fusilev, and generic formulations) effective immediately. Coverage is now limited to three specific indications: osteosarcoma with high-dose methotrexate, impaired methotrexate elimination/overdose, and advanced metastatic colorectal cancer. All three indications require documented failure or intolerance of prior leucovorin calcium therapy before levoleucovorin will be approved.
Medium impact
Jemperli (dostarlimab-gxly)
Humana·Effective Nov 1, 2025
Humana Indiana Medicaid implemented a new prior authorization policy for Jemperli (dostarlimab-gxly), an immunotherapy for endometrial cancer and dMMR solid tumors, effective November 1, 2025. The policy establishes three covered indications (frontline endometrial cancer with chemotherapy, second-line+ endometrial cancer, and dMMR solid tumors) with specific clinical criteria and exclusions. All uses require prior authorization with approval durations of plan year for frontline therapy and 6 months for subsequent therapies.
Medium impact
Jemperli (dostarlimab-gxly)
Humana·Effective Nov 1, 2025
Humana Louisiana Medicaid has established a new Prior Authorization policy for Jemperli (dostarlimab-gxly), effective November 1, 2025. The policy covers three indications: frontline endometrial cancer (in combination with chemotherapy), second-line endometrial cancer (dMMR, monotherapy), and dMMR solid tumors (monotherapy). All requests require prior authorization with specific clinical criteria, and claims will be denied if patients have disease progression on prior anti-PD-1/PD-L1 therapy.
Medium impact
Jemperli (dostarlimab-gxly)
Humana·Effective Nov 1, 2025
Humana Medicaid Ohio has established a new prior authorization policy for Jemperli (dostarlimab-gxly), an immunotherapy drug for endometrial cancer and dMMR solid tumors. The policy effective November 1, 2025 defines three coverage pathways: (1) frontline endometrial cancer in combination with carboplatin/paclitaxel followed by maintenance, (2) second-line or beyond dMMR endometrial cancer as monotherapy, and (3) unresectable/metastatic dMMR solid tumors as monotherapy. All approvals require prior authorization and exclude patients with prior anti-PD-1/PD-L1 therapy progression.
High impact
Faslodex (fulvestrant)
Humana·Effective Nov 1, 2025
Humana Indiana Medicaid has implemented a new prior authorization policy for Faslodex (fulvestrant) effective November 1, 2025. The policy requires prior authorization for all fulvestrant use in breast cancer treatment, with specific clinical criteria for monotherapy versus combination therapy with CDK 4/6 inhibitors. Billing teams must identify all fulvestrant claims and obtain pre-approval before dispensing to avoid claim denials.
Medium impact
Faslodex (fulvestrant)
Humana·Effective Nov 1, 2025
Humana Ohio Medicaid implemented a new prior authorization policy for Faslodex (fulvestrant) effective November 1, 2025, for HR-positive, HER2-negative advanced breast cancer. The policy establishes specific approval criteria for monotherapy and combination therapy with CDK 4/6 inhibitors, requiring documentation of menopausal status, prior endocrine therapy history, and disease progression details.
Medium impact
Bizengri (zenocutuzumab-zbco)
Humana·Effective Jan 1, 2026
Humana Medicaid-Indiana has established a new prior authorization policy for Bizengri (zenocutuzumab-zbco), effective January 1, 2026. This bispecific antibody is now covered for advanced/metastatic NSCLC and pancreatic adenocarcinoma with NRG1 gene fusion positive status in patients with prior systemic therapy. All Bizengri claims require prior authorization and must meet specific clinical criteria to avoid denial.
Medium impact
Bizengri (zenocutuzumab-zbco)
Humana·Effective Jan 1, 2026
Humana Louisiana Medicaid has established a new prior authorization policy for Bizengri (zenocutuzumab-zbco), effective January 1, 2026. The policy covers NRG1 gene fusion-positive advanced/unresectable/metastatic NSCLC and pancreatic adenocarcinoma in patients with at least one prior line of systemic therapy, requiring prior auth and denying coverage for patients with prior disease progression on the drug.
Medium impact
Bizengri (zenocutuzumab-zbco)
Humana·Effective Jan 1, 2026
Humana Medicaid (Ohio) has implemented a new prior authorization policy for Bizengri (zenocutuzumab-zbco), effective January 1, 2026. Coverage is limited to NRG1 gene fusion-positive advanced/unresectable/metastatic NSCLC or pancreatic adenocarcinoma patients with at least one prior systemic therapy line, used as monotherapy. Claims will require prior authorization demonstrating medical necessity and meeting all clinical criteria.
High impact
Soliris® (eculizumab) and biosimilars (New)
Humana·Effective Aug 1, 2026
Humana Medicaid (Ohio) has implemented a new prior authorization policy effective August 1, 2026, for Soliris® (eculizumab) and biosimilars (Bkemv, Epysqli) covering four rare conditions: PNH, aHUS, gMG, and NMOSD. The policy establishes specific clinical criteria for approval, including diagnostic confirmations, antibody testing, specialist supervision, and prior treatment requirements depending on indication. Billing teams must implement prior authorization workflows immediately to avoid claim denials for these high-cost specialty medications.
High impact
Spinal Fusion and Stabilization Surgery - MEDICAID - KENTUCKY (New)
Humana·Effective Aug 5, 2026
Humana Kentucky Medicaid has issued a new comprehensive policy (HUM-KY-2235-000) establishing coverage criteria and prior authorization requirements for spinal fusion, stabilization, and related procedures including corpectomy, kyphectomy, artificial disc replacement, sacroiliac joint fusion, spinal osteotomy, and spinal fusion surgery. This policy is effective immediately (08/05/2026) and applies to all spinal procedures covered under Kentucky Medicaid.
High impact
Spinal Decompression Surgery - MEDICAID - OHIO (New)
Humana·Effective Aug 5, 2026
Humana Healthy Horizons Ohio Medicaid has issued a new clinical coverage policy for spinal decompression surgery effective 08/05/2026. The policy establishes medical necessity criteria and prior authorization requirements for various spinal decompression procedures including laminectomy, laminotomy, foraminectomy, foraminotomy, and related surgeries. The policy document is incomplete (appears truncated), but establishes that procedures require prior authorization and must meet specific clinical criteria to be covered.
High impact
Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 5, 2026
NC Medicaid - NCDHHS·Effective Aug 1, 2026
NC Medicaid updated its Research-Based Behavioral Health Treatment (RB-BHT) policy effective August 1, 2026, requiring paraprofessionals to obtain BACB or QABA certification within 120 days, removing telehealth for paraprofessional services (CPT 97152-97154), limiting LQASP telehealth to 50% of visits, and requiring quarterly reauthorization for treatment plans exceeding 16 hours per week. Billing teams must immediately stop accepting telehealth claims for paraprofessional RB-BHT services and implement new prior authorization and supervision documentation requirements.
High impact
Medical Policy Updates August 5, 2026
Blue Cross NC·Effective Aug 5, 2026
Blue Cross NC issued a comprehensive medical policy update effective August 5, 2026, affecting 11 clinical policies including allergen testing, cardiovascular risk assessment, sexually transmitted infection testing, and colorectal cancer screening. Multiple billing codes were added, removed, or modified across these policies, requiring immediate system updates and billing team training to ensure accurate claim submission and avoid denials.
Medium impact
Reimbursement Rate Updates for HCPCS Drug Procedure Code J8502 Effective April 1, 2026
Texas Medicaid·Effective Apr 1, 2026
Texas Medicaid (TMHP) has updated reimbursement rates for HCPCS code J8502 effective April 1, 2026. The new rates apply to the Children with Special Health Care Needs (CSHCN) Services Program. TMHP will automatically identify and reprocess affected claims, with adjustments appearing on future Remittance and Status Reports.

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Archive by year

2023 2024 2025 2026

Levoleucovorin products (Revised)

Idhifa® (enasidenib) (Revised)

Jemperli (dostarlimab-gxly) (Revised)

Rezurock (belumosudil) (Revised)

Levoleucovorin products (Revised)

Rezlidhia (olutasidenib) (Revised)

Orserdu (elacestrant) (Revised)

Levoleucovorin products (Revised)

Faslodex (fulvestrant) (Revised)

Alternate nilotinib products (Danziten, Cavhanza, nilotinib tartrate-Cipla) (Revised)

Levoleucovorin products

Jemperli (dostarlimab-gxly)

Jemperli (dostarlimab-gxly)

Jemperli (dostarlimab-gxly)

Faslodex (fulvestrant)

Faslodex (fulvestrant)

Bizengri (zenocutuzumab-zbco)

Bizengri (zenocutuzumab-zbco)

Bizengri (zenocutuzumab-zbco)

Soliris® (eculizumab) and biosimilars (New)

Spinal Fusion and Stabilization Surgery - MEDICAID - KENTUCKY (New)

Spinal Decompression Surgery - MEDICAID - OHIO (New)

Updated Reminder: Requirements for Research-Based Behavioral Health Treatment Service Delivery – Aug. 5, 2026

Medical Policy Updates August 5, 2026

Reimbursement Rate Updates for HCPCS Drug Procedure Code J8502 Effective April 1, 2026