All Insurance Policy Changes (Page 69)

Continuing from page 68. 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
[Virginia] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are expanding their specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must implement prior authorization workflows for these medications or face claim denials.
Medium impact
[Virginia] Continued collaboration on DRG clinical and coding validation
Anthem BCBS·Effective Jul 22, 2026
HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) will continue conducting DRG clinical and coding validation audits through its internal Complex and Clinical Audit team and designated external vendors (EXL and Ceris). Providers should expect to receive medical record requests from HealthKeepers and/or vendor partners as part of ongoing DRG validation activities, with efforts made to minimize duplicate requests.
Medium impact
[Georgia] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·Effective Nov 1, 2026
Effective November 1, 2026, Anthem Blue Cross Blue Shield (Medicare Advantage) in Georgia is expanding its specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must obtain precertification for these drugs before dispensing to avoid claim denials.
Medium impact
Annual Chlamydia Screening for PA CHIP Members Age 16+
Highmark·Effective Jul 22, 2026
Highmark PA CHIP now requires annual chlamydia screening for sexually active females ages 16+. This screening is covered at no cost as preventive care and is part of NCQA HEDIS performance metrics. Providers should implement annual screening protocols during well-child visits and use trauma-informed, patient-centered approaches when discussing sexual health.
Medium impact
Best Coding Practices: Migraines
Highmark·Effective Jul 22, 2026
Highmark has published updated best coding practices for migraine diagnosis and treatment, emphasizing the use of ICD-10 codes from category G43 to accurately characterize migraine type and reflect disease burden. Providers should reference the updated Coding Education resources on the Provider Resource Center for comprehensive coding guidance and video presentations.
High impact
Reminder: Annual Medicare Compliance Training
Highmark·Identified Jul 23, 2026
Highmark is reminding all Medicare providers and facilities that annual compliance training on fraud, waste, and abuse (FWA) is mandatory for all employees, contractors, volunteers, and governing-body members who work with Medicare Advantage and Part D members. Training must be completed within 90 days of hire and annually between January 1-December 31, with documentation maintained for the contract period plus 10 years.
Medium impact
Prevymis™ (letermovir) (Revised)
Humana·Effective Jul 22, 2026
This is a revised Prevymis (letermovir) prior authorization policy for Medicaid in Kentucky, South Carolina, and Virginia. The policy clarifies coverage for CMV prophylaxis in allogeneic hematopoietic stem cell transplant (HSCT) recipients (R+) and for CMV prophylaxis/treatment in solid organ transplant recipients who cannot tolerate valganciclovir. All requests require prior authorization with specific clinical criteria, age/weight requirements, and approval durations up to 12 months.
High impact
Simponi ARIA (golimumab) (Revised)
Humana·Effective Jan 1, 2019
This is a revised Simponi ARIA (golimumab) prior authorization policy for Medicaid in South Carolina, effective January 1, 2019, with the most recent revision dated July 22, 2026. The policy outlines specific clinical criteria and exclusions for coverage across four indications: ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis, and polyarticular juvenile idiopathic arthritis. Key requirements include prior NSAID/DMARD therapy, age restrictions, contraindications to combination biologic therapy, and mandatory methotrexate co-therapy for rheumatoid arthritis unless contraindicated.
Medium impact
Topical Antifungals (Revised)
Humana·Effective Jan 1, 2020
This is a Step Therapy policy for topical antifungal medications (Exelderm, Luzu, Naftin, and sulconazole products) that requires members to have failed or be intolerant to two first-line topical antifungals (clotrimazole, ciclopirox, or ketoconazole) within the past 12 months before coverage is approved. The policy was revised on July 22, 2026, establishing the current authorization criteria for these medications.
Medium impact
Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)
Humana·Effective Sep 15, 2021
This is a revised Humana prior authorization policy for Rylaze (asparaginase Erwinia chrysanthemi recombinant-rywn) effective September 15, 2021, with a recent revision date of July 22, 2026. The policy requires prior authorization for Rylaze when used to treat ALL or Lymphoblastic Lymphoma in patients with Grade 2-4 hypersensitivity to prior Oncaspar treatment. The policy applies to Medicare, Medicaid in Kentucky, and Medicaid in South Carolina.
Low impact
Skyrizi® (risankizumab-rzaa) (Revised)
Humana·Effective Jul 22, 2026
Humana updated its Skyrizi (risankizumab-rzaa) prior authorization policy effective July 22, 2026. The policy maintains existing coverage criteria for four indications: plaque psoriasis (age 6+, with prior conventional oral systemic therapy requirement), psoriatic arthritis (age 6+), Crohn's disease (age 18+), and ulcerative colitis (age 18+). All approvals are granted in plan year durations or through clinical review. This is a routine policy revision with no substantive coverage changes from the previous version.
Medium impact
Xipere® (triamcinolone acetonide) (Revised)
Humana·Effective Jul 22, 2026
Humana's Xipere (triamcinolone acetonide) policy for Medicaid members in Kentucky and South Carolina was revised on July 22, 2026. This is a prior authorization requirement for the intraocular suspension used to treat macular edema associated with uveitis. The policy requires members to have a confirmed diagnosis of macular edema associated with uveitis to qualify for coverage.
Medium impact
Tecvayli (teclistamab-cqyv) (Revised)
Humana·Effective Jul 22, 2026
Humana revised its Tecvayli (teclistamab-cqyv) prior authorization policy effective July 22, 2026, for Medicare and three Medicaid state programs (Florida, Kentucky, South Carolina). The policy maintains two coverage pathways: monotherapy for patients with ≥4 prior therapy lines including specific drug classes, or combination with daratumumab for patients with ≥1 prior line. Billing teams must ensure prior authorization is obtained before dispensing and verify patient eligibility under the specific treatment pathway (monotherapy vs. combination).
Low impact
Pyrukynd® (mitapivat) (Revised)
Humana·Effective Jan 1, 2023
Humana Medicare Advantage updated its Pyrukynd (mitapivat) prior authorization policy effective January 1, 2023, with a revision dated July 22, 2026. The policy requires prior authorization for Pyrukynd coverage in Medicare Advantage members with pyruvate kinase deficiency and hemolytic anemia, with three specific clinical criteria that must be met before approval. Billing teams must ensure all Pyrukynd claims include documented genetic testing results, hemoglobin levels, and meet exclusion criteria before submission.
Medium impact
Talvey (talquetamab) (Revised)
Humana·Effective Nov 22, 2023
This is a recent revision (July 22, 2026) of Humana's Talvey (talquetamab) prior authorization policy for multiple myeloma treatment. The policy applies to Medicare and Medicaid plans in Florida, Kentucky, and South Carolina. All requests for Talvey require prior authorization and must meet strict clinical criteria: diagnosis of relapsed/refractory multiple myeloma, at least four prior lines of therapy including specific drug classes, and single-agent use only. Claims will be denied if the patient experiences disease progression while on Talvey.
Low impact
Voydeya™ (danicopan) tablet (Revised)
Humana·Effective Sep 25, 2024
This is a new Medicare Advantage prior authorization policy for Voydeya (danicopan) tablet, effective September 25, 2024. The policy requires prior authorization for Voydeya as add-on therapy to eculizumab or ravulizumab in PNH patients with clinically significant extravascular hemolysis. Billing teams must implement prior authorization requirements and validate that all four clinical criteria are met before claims are processed.
Medium impact
Vyloy (zolbetuximab-clzb) (Revised)
Humana·Effective Nov 27, 2024
Humana has established a new prior authorization policy for Vyloy (zolbetuximab-clzb), a specialized cancer immunotherapy for HER2-negative gastric and gastroesophageal junction adenocarcinoma. This policy applies to Medicare, Kentucky Medicaid, and South Carolina Medicaid members and requires prior authorization before dispensing, with specific clinical criteria including CLDN18.2-positive tumor confirmation and first-line combination chemotherapy use.
Medium impact
Vyepti® (eptinezumab) (Revised)
Humana·Effective Jan 1, 2025
Humana updated its Vyepti (eptinezumab) prior authorization policy for Medicare Advantage plans effective January 1, 2025. The policy requires step therapy with both Emgality AND Qulipta before Vyepti approval for migraine prevention, with exceptions for Medicare Part B continuations and PDP/MA-only plans. Billing teams must ensure prior authorization is obtained and step therapy requirements are documented before claim submission.
Medium impact
Voquezna® (vonoprazan) (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its Voquezna (vonoprazan) prior authorization policy for Medicare Advantage members, effective January 1, 2025. This is a pharmacy coverage policy requiring prior authorization for three indications: erosive esophagitis (requires 8-week PPI trial failure + endoscopy confirmation), H. pylori infection (requires trial/contraindication to Talicia), and non-erosive GERD (requires 4-week max duration + prior PPI failure). Billing teams must implement prior auth verification before dispensing and ensure providers meet all documented criteria.
Medium impact
Tremfya (guselkumab) (Revised)
Humana·Effective Jan 1, 2025
Humana has issued a revised Medicare Advantage prior authorization policy for Tremfya (guselkumab) effective January 1, 2025, covering four indications: plaque psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease. The policy requires prior authorization for all formulations (IV and subcutaneous) with specific clinical criteria based on diagnosis, age, weight, and prior treatment history. Billing teams must ensure all Tremfya claims include appropriate prior authorization before submission to avoid denials.
Medium impact
Ruconest (C1 esterase inhibitor, recombinant) (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its Ruconest (C1 esterase inhibitor, recombinant) prior authorization policy effective January 1, 2025, with a revision dated July 22, 2026. This policy applies to Medicare, Medicaid-Kentucky, and Medicaid-South Carolina. The policy requires prior authorization for acute HAE attack treatment with eight specific approval criteria, including HAE diagnosis confirmation with lab documentation, specialist treatment requirement, and step-therapy waiver for Medicaid (but applies to Medicare Part B). Billing teams must ensure all prior authorization requirements are met before claims are submitted to avoid denials.
Medium impact
Qulipta (atogepant) (Revised)
Humana·Effective Jan 1, 2025
Humana Medicare Advantage has established a prior authorization requirement for Qulipta (atogepant), a CGRP receptor antagonist used for migraine prevention in adults. The policy requires prior auth approval for initial and renewal periods, with specific dosage adjustments for patients with severe renal impairment or ESRD. This is a new pharmacy coverage policy effective January 1, 2025.
Medium impact
PiaSky® (crovalimab-akkz) injection (Revised)
Humana·Effective Jan 1, 2025
Humana has updated its prior authorization policy for PiaSky® (crovalimab-akkz) injection, a complement C5 inhibitor for treating Paroxysmal Nocturnal Hemoglobinuria (PNH). The policy, effective January 1, 2025 and revised July 22, 2026, requires prior authorization for all PiaSky requests across Medicare and specific Medicaid programs (Florida, Kentucky, South Carolina, Virginia). Billing teams must verify patients meet all clinical criteria including confirmed PNH diagnosis via flow cytometry, weight ≥40 kg, clinical hemolysis or transfusion dependence, and for Medicare Part B, step therapy with Ultomiris unless continuing prior therapy within 365 days.
Medium impact
Firazyr (icatibant) (Revised)
Humana·Effective Jan 1, 2025
Humana's revised Firazyr (icatibant) policy for Kentucky Medicaid and Medicare clarifies prior authorization requirements for HAE treatment, distinguishing between HAE Type 1/2 (with C1-INH deficiency) and HAE Type 3 (with normal C1-INH). Key change: For Medicaid requests, step therapy requirements do not apply, meaning prior generic icatibant trial is NOT required for brand Firazyr approval.
High impact
Zepbound® (tirzepatide) (Revised)
Humana·Effective Jan 20, 2025
Humana Medicare Advantage now covers Zepbound (tirzepatide) for moderate to severe obstructive sleep apnea (OSA) in obese adults as of January 20, 2025. This is a NEW indication requiring prior authorization with specific clinical criteria including BMI ≥30, AHI/REI ≥15, and documented lifestyle modifications. Patients with type 1 or type 2 diabetes are excluded from coverage under this indication.

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Archive by year

2023 2024 2025 2026

[Virginia] Expansion of the Specialty Pharmacy precertification list

[Virginia] Continued collaboration on DRG clinical and coding validation

[Georgia] Expansion of the Specialty Pharmacy precertification list

Annual Chlamydia Screening for PA CHIP Members Age 16+

Best Coding Practices: Migraines

Reminder: Annual Medicare Compliance Training

Prevymis™ (letermovir) (Revised)

Simponi ARIA (golimumab) (Revised)

Topical Antifungals (Revised)

Rylaze (asparaginase erwinia chrysanthemi (recombinant)-rywn) (Revised)

Skyrizi® (risankizumab-rzaa) (Revised)

Xipere® (triamcinolone acetonide) (Revised)

Tecvayli (teclistamab-cqyv) (Revised)

Pyrukynd® (mitapivat) (Revised)

Talvey (talquetamab) (Revised)

Voydeya™ (danicopan) tablet (Revised)

Vyloy (zolbetuximab-clzb) (Revised)

Vyepti® (eptinezumab) (Revised)

Voquezna® (vonoprazan) (Revised)

Tremfya (guselkumab) (Revised)

Ruconest (C1 esterase inhibitor, recombinant) (Revised)

Qulipta (atogepant) (Revised)

PiaSky® (crovalimab-akkz) injection (Revised)

Firazyr (icatibant) (Revised)

Zepbound® (tirzepatide) (Revised)