All Insurance Policy Changes (Page 78)

Continuing from page 77. 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
Angiotensin Blocking Agents (Revised)
Humana·Effective Jan 1, 2023
This is a revised Step Therapy policy for Angiotensin Blocking Agents (Arbli, azilsartan, Edarbi, Edarbyclor, and valsartan oral solution) under Medicare Advantage. The policy requires members to have prior treatment with at least two ACE inhibitors or ARBs before coverage is approved for the listed angiotensin blocking agents. This represents a gatekeeping requirement for pharmacy coverage.
Medium impact
FILSPARI® (sparsentan) (Revised)
Humana·Effective Jul 22, 2026
Humana has revised its FILSPARI (sparsentan) prior authorization policy for Medicare Advantage members, effective July 22, 2026. The policy covers two indications: primary IgAN (requiring biopsy confirmation, ACEi/ARB trial/failure or contraindication, and eGFR ≥30) and FSGS without nephrotic syndrome (age 8+, requiring ACEi/ARB trial/failure or contraindication, and eGFR ≥30). Key update: pregnancy testing requirement was removed from the REMS program in August 2025, though pregnancy must still be excluded before initiation. Prior authorization is required for all FILSPARI prescriptions.
Medium impact
Litfulo™ (ritlecitinib) (Revised)
Humana·Effective Jul 22, 2026
Humana Medicare Advantage updated its prior authorization policy for Litfulo (ritlecitinib) for severe alopecia areata, effective July 22, 2026. The policy requires prior authorization and mandates that patients meet all three criteria: severe alopecia areata with ≥50% scalp hair loss documented by SALT score for 6+ months, prior treatment/contraindication/intolerance to corticosteroids or cyclosporine, and no concurrent use with other JAK inhibitors or potent immunosuppressants. Claims submitted without meeting these criteria or without prior authorization will be denied.
Medium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·Effective Nov 15, 2023
This is a revised Humana prior authorization policy for Elrexfio (elranatamab-bcmm), a bispecific BCMA-directed CD3 T-cell engager for relapsed/refractory multiple myeloma. The policy requires prior authorization and establishes strict clinical criteria including diagnosis of relapsed/refractory multiple myeloma, receipt of at least four prior lines of therapy (including specific drug classes), and single-agent use only. A critical exclusion applies: members with prior disease progression on BCMA-directed bispecific regimens are not eligible.
Medium impact
Empaveli (pegcetacoplan) (Revised)
Humana·Effective Jan 1, 2024
This is a revised Humana prior authorization policy for Empaveli (pegcetacoplan) effective January 1, 2024, with the most recent revision dated July 22, 2026. The policy covers two indications: Paroxysmal Nocturnal Hemoglobinuria (PNH) and Complement 3 Glomerulopathy (C3G) or primary immune-complex membranoproliferative glomerulonephritis (IC-MPGN). For PNH, prior authorization requires documented diagnosis with specific clone size and LDH levels, plus transfusion dependence or thrombotic history. For C3G/IC-MPGN, authorization requires biopsy confirmation, age 12+, and documented failure or contraindication to immunosuppressive therapies and glucocorticoids. All requests require prior authorization before dispensing.
Medium impact
Adzynma (ADAMTS13, Recombinant-krhn) (Revised)
Humana·Effective Apr 24, 2024
This is a new Humana prior authorization policy for Adzynma (ADAMTS13, recombinant-krhn), a rare enzyme replacement therapy for congenital thrombotic thrombocytopenic purpura (cTTP). The policy establishes four mandatory approval criteria requiring confirmed cTTP diagnosis, ADAMTS13 activity <10 IU/dL, molecular genetic testing confirmation, and repeated negative antibody testing. Billing teams must implement prior authorization requirements for Kentucky and South Carolina Medicaid and all Medicare lines before dispensing.
Medium impact
Fabhalta® (iptacopan) capsule (Revised)
Humana·Effective May 22, 2024
This is a revised Humana Medicare Advantage prior authorization policy for Fabhalta® (iptacopan) covering four indications: PNH (new start and stable), primary IgAN, and C3G. The policy establishes specific clinical criteria that must be met before approval, including diagnostic confirmations, laboratory markers, and documented disease severity or treatment failures. Billing teams must ensure prior authorization is obtained before dispensing and verify all clinical criteria are documented.
High impact
Epoetin Alfa (Epogen, Procrit, Retacrit) (Revised)
Humana·Effective Jan 1, 2025
Humana has revised its Epoetin Alfa (Epogen, Procrit, Retacrit) prior authorization policy effective January 1, 2025, establishing unified clinical criteria across Medicare and Medicaid (South Carolina and Virginia) for seven anemia indications. The policy requires prior authorization for all three products, specifies preferred vs. non-preferred product hierarchies with step-therapy requirements, and mandates documentation of hemoglobin levels, iron stores, and exclusion of other anemia causes before approval.
Medium impact
Calcitonin gene-related peptide (CGRP) inhibitors (Revised)
Humana·Effective Jan 1, 2025
This is a revised Medicare Advantage prior authorization policy for CGRP inhibitors (Aimovig, Ajovy, Emgality) effective January 1, 2025, with updates as of July 22, 2026. The policy establishes specific authorization criteria: for Emgality episodic cluster headache treatment, members must have diagnosed episodic cluster headaches and failed verapamil trial; for migraine prevention with Aimovig or Ajovy, members must have prior treatment with both Emgality AND Qulipta. All CGRP inhibitor requests require prior authorization before dispensing.
Medium impact
Berinert (C1 esterase inhibitor, human) (Revised)
Humana·Effective Jan 1, 2025
This is a revised Berinert (C1 esterase inhibitor) prior authorization policy for Humana Medicare and Medicaid (Kentucky and South Carolina) effective January 1, 2025. The policy establishes 8 detailed approval criteria requiring HAE Type 1/2 diagnosis confirmation, specific lab documentation (C4, C1INH levels, and C1q levels), specialist treatment, and step-therapy with generic icatibant for Medicare Part B (waived for Medicaid). Billing teams must implement prior authorization requirements before submitting claims for this injectable medication.
High impact
Aranesp® (darbepoetin alfa) (Revised)
Humana·Effective Jan 1, 2025
This is a revised Aranesp (darbepoetin alfa) prior authorization policy for Humana Medicare and Medicaid (South Carolina) effective January 1, 2025. The policy establishes clinical criteria for coverage across three indications: anemia of chronic kidney disease, anemia in chemotherapy-treated cancer members, and anemia in myelodysplastic syndromes. Key requirements include baseline hemoglobin/hematocrit thresholds, iron store evaluation, exclusion of other anemia causes, and step therapy (inadequate response to Retacrit/Procrit for 2+ months) before approval. Continuation therapy requires documented iron stores and ongoing hemoglobin monitoring.
Medium impact
Alternate nilotinib products (Danziten, Cavhanza, nilotinib tartrate-Cipla) (Revised)
Humana·Effective Feb 26, 2025
This revised Humana Medicare Advantage prior authorization policy covers three alternate nilotinib products (Danziten, Cavhanza, and nilotinib tartrate-Cipla) for chronic myeloid leukemia treatment. The policy requires prior authorization and establishes approval criteria: members must have a CML diagnosis, be 18+ years old, and have not experienced disease progression on any prior nilotinib product. A black box warning highlights QT prolongation risks and requires baseline/periodic ECG monitoring.
Medium impact
Orencia (abatacept) Subcutaneous (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Orencia (abatacept) subcutaneous injection, effective January 1, 2026. The policy requires prior authorization for three indications (Psoriatic Arthritis, Rheumatoid Arthritis, and Polyarticular Juvenile Idiopathic Arthritis) with specific age requirements and mandatory prior therapy with two drugs from defined lists before Orencia can be approved.
High impact
Orencia (abatacept) Intravenous (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for Orencia (abatacept) intravenous effective January 1, 2026, updated July 22, 2026. The policy establishes specific step-therapy requirements for four indications (Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, Psoriatic Arthritis, and Graft vs. Host Disease prophylaxis), requiring documented prior therapy or contraindication with specified biologics before approval. Key restriction: Orencia cannot be used in combination with other biologics, and Medicare Part B continuation therapy within 365 days is exempt from step-therapy requirements.
Medium impact
Olumiant (baricitinib) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Olumiant (baricitinib) prior authorization policy for Medicare Advantage, effective January 1, 2026, with updates finalized July 22, 2026. The policy maintains prior authorization requirements for two indications: rheumatoid arthritis (requires failure/intolerance to two specific TNF antagonists or JAK inhibitors) and severe alopecia areata (requires 50%+ scalp hair loss and prior corticosteroid/cyclosporine failure). Billing teams must ensure claims include documentation of prior treatment history and severity criteria before submission.
Medium impact
Juxtapid® (lomitapide) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Juxtapid (lomitapide) prior authorization policy for Medicare Advantage members with homozygous familial hypercholesterolemia (HoFH). The policy requires prior authorization and mandates that members must have failed, been intolerant to, or have contraindications to Repatha (evolocumab) before Juxtapid approval. Additionally, members must document initiation of a low-fat diet (<20% fat) and specific vitamin/fatty acid supplementation (vitamin E, linoleic acid, omega-3 fatty acids) prior to starting treatment.
High impact
Enbrel (etanercept) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Humana Medicare Advantage prior authorization policy for Enbrel (etanercept) effective January 1, 2026, with updates as of July 22, 2026. The policy establishes specific clinical criteria for coverage across six indications (ankylosing spondylitis, plaque psoriasis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and juvenile psoriatic arthritis), including age requirements, disease severity specifications, and prior therapy/contraindication/intolerance documentation requirements. All Enbrel prescriptions require prior authorization approval on a plan year basis before dispensing.
High impact
Injections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (Revised)
Humana·Effective Jul 29, 2026
Humana Oklahoma Medicaid updated its policy for chronic pain injections (epidural steroid injections, facet joint injections, sacroiliac joint injections, trigger point injections, and peripheral nerve blocks) effective July 29, 2026. The policy establishes specific coverage criteria including mandatory 4-week conservative treatment, radicular pain confirmation, imaging guidance requirements, and strict frequency/level limitations for procedures. Billing teams must ensure prior authorization compliance and proper documentation of conservative treatment attempts before claim submission.
Medium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (New)
Humana·Identified Jul 22, 2026
Oklahoma Medicaid has established a new coverage policy for Fractional Flow Reserve with Computed Tomography (FFR-CT), a noninvasive diagnostic test used to evaluate coronary artery blood flow in patients with known or suspected coronary artery disease. This policy defines coverage for FFR-CT imaging when derived from cardiac computed tomography angiography (CCTA) data.
Medium impact
Durable Medical Equipment Maintenance and Repair - MEDICAID - LOUISIANA (New)
Humana·Effective Jul 29, 2026
Humana Louisiana Medicaid (Healthy Horizons) established a new DME maintenance and repair coverage policy effective 07/29/2026. Coverage requires prior authorization and is subject to strict conditions: equipment must be medically necessary, personally owned, used exclusively by the beneficiary, not under warranty, and damage cannot result from misuse, abuse, neglect, or loss. Billing teams must implement prior authorization workflows and denial protocols for claims involving stolen, destroyed, or negligently damaged equipment.
High impact
Documentation Requirements for Hysterectomy and Sterilization - MEDICAID - LOUISIANA (New)
Humana·Effective Jul 29, 2026
Louisiana Medicaid (Humana Healthy Horizons) implemented new documentation requirements for hysterectomy and sterilization procedures effective 07/29/2026. Billing teams must ensure providers obtain and submit specific consent forms (BHSF Form 96-A for hysterectomy; HHH-687/HHH-687-1 for sterilization) signed by required parties before claims can be processed and reimbursed. Claims will be denied without proper documentation, witness signatures when applicable, and name verification.
Medium impact
07-16-2026 Provider Disputes IM IE LA OC SAC SD
Molina Healthcare·Effective Jul 16, 2026
Molina Healthcare of California issued a provider bulletin clarifying the process for submitting Provider Claims Disputes across six California regions (Imperial, Riverside, San Bernardino, Los Angeles, Orange, Sacramento, San Diego). The policy reinforces the preferred method of dispute submission through the Availity Essentials Portal and establishes a 45 working day resolution timeline after receipt of complete disputes. This is a procedural reminder rather than a substantive policy change.
High impact
07-16-2026 Stay Informed Medi-Cal Rx Updates and Provider Enrollment Reminder IE LA SAC SD
Molina Healthcare·Identified Jul 22, 2026
Molina Healthcare of California is implementing a new enrollment requirement effective soon whereby only enrolled Medi-Cal providers (doctors, nurse practitioners, physician assistants, and pharmacists) can submit prescriptions for reimbursement. Providers must verify their enrollment status immediately and apply through the PAVE portal if not yet enrolled, as unenrolled providers will face claim denials and care disruptions. The bulletin also alerts providers to multiple formulary and coverage updates including Basaglar removal from the contract drug list (effective August 9, 2026), GLP-1 coverage changes, and updated coordination of benefits rules.
High impact
07-16-2026 Timely access standards IM IE LA OC SAC SD
Molina Healthcare·Effective Jul 16, 2026
Molina Healthcare of California issued updated timely access standards for Medi-Cal and Marketplace plans across seven California regions, establishing mandatory appointment scheduling timeframes for PCPs, specialists, behavioral health providers, and ancillary services. The policy requires 24/7 availability with after-hours backup coverage and specifies response times for phone calls, office wait times, and emergency protocols. This is a regulatory compliance advisory affecting all network providers in the specified service areas.
High impact
Clinical Coverage Policy Update 1A-20 Sleep Studies and Polysomnography Services
NC Medicaid - NCDHHS·Effective Jul 1, 2026
NC Medicaid expanded coverage for sleep studies and polysomnography services effective July 1, 2026, adding new diagnosis criteria (Restless Legs Syndrome, Chronic Insomnia, Snoring with specific symptoms, neuromuscular disorders with sleep symptoms) and removing prior authorization requirements for unattended home sleep tests. Facility-based sleep studies are now covered when home equipment is unavailable or cannot be operated. All claims must include documentation of Clinical Coverage Policy 1A-20 criteria.

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Archive by year

2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 78) | PolicyChanges.app

Angiotensin Blocking Agents (Revised)

FILSPARI® (sparsentan) (Revised)

Litfulo™ (ritlecitinib) (Revised)

Elrexfio (elranatamab-bcmm) (Revised)

Empaveli (pegcetacoplan) (Revised)

Adzynma (ADAMTS13, Recombinant-krhn) (Revised)

Fabhalta® (iptacopan) capsule (Revised)

Epoetin Alfa (Epogen, Procrit, Retacrit) (Revised)

Calcitonin gene-related peptide (CGRP) inhibitors (Revised)

Berinert (C1 esterase inhibitor, human) (Revised)

Aranesp® (darbepoetin alfa) (Revised)

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

Orencia (abatacept) Subcutaneous (Revised)

Orencia (abatacept) Intravenous (Revised)

Olumiant (baricitinib) (Revised)

Juxtapid® (lomitapide) (Revised)

Enbrel (etanercept) (Revised)

Injections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (Revised)

Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (New)

Durable Medical Equipment Maintenance and Repair - MEDICAID - LOUISIANA (New)

Documentation Requirements for Hysterectomy and Sterilization - MEDICAID - LOUISIANA (New)

07-16-2026 Provider Disputes IM IE LA OC SAC SD

07-16-2026 Stay Informed Medi-Cal Rx Updates and Provider Enrollment Reminder IE LA SAC SD

07-16-2026 Timely access standards IM IE LA OC SAC SD

Clinical Coverage Policy Update 1A-20 Sleep Studies and Polysomnography Services