All Insurance Policy Changes (Page 81)

Continuing from page 80. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

Low impact
ICF Quarterly Webinar with HHSC LTCR
Texas Medicaid·Effective Aug 5, 2026
HHSC Long-Term Care Regulation is hosting a quarterly webinar on August 5, 2026, for ICF (Intermediate Care Facility) and IID (Intermediate Care for Individuals with Intellectual Disabilities) providers. This is an educational/informational webinar with no direct impact on billing codes, coverage, or reimbursement policies. The content replicates a previous July 15, 2026 webinar. Note: Internet Explorer users should use alternative browsers for registration.
Low impact
Updated OASIS Training Opportunity for Licensed and Certified Home Health Agencies
Texas Medicaid·Identified Jul 21, 2026
CMS has released an updated OASIS training resource for home health agencies covering requirements for reporting Outcome and Assessment Information Set (OASIS-E2) data to the iQIES system. This training addresses compliance with reporting regulations, OASIS submission procedures, validation report interpretation, and All-Payer OASIS submission requirements. While this is educational content rather than a billing policy change, home health billing teams should ensure their staff responsible for OASIS reporting are familiar with the updated training materials.
High impact
Providers Must Have a Valid Email Address on Record to Access TMHP Applications Through TMHP IAMOnline
Texas Medicaid·Effective Aug 3, 2026
TMHP is transitioning the My Account portal to TMHP IAMOnline on August 3, 2026. All Texas Medicaid providers must verify their email address is valid and active in My Account by July 30, 2026, to receive activation credentials for the new system. Providers with outdated or invalid emails will lose portal access and must file a manual form to regain it, causing significant delays.
Low impact
IAMOnline Educational Video Now Available
Texas Medicaid·Identified Jul 21, 2026
TMHP has released a new educational video titled 'IAMOnline' to help providers activate and manage their TMHP IAMOnline accounts. The video covers account activation, multifactor authentication (MFA) setup, and the 90-day inactivity policy. This is a training resource update with no billing or coverage changes.
Medium impact
26-857 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination
Health Net·Identified Jul 21, 2026
HealthNet California is offering a limited-time financial incentive of $70 per eligible eConsult submitted and billed through ConferMED through October 1, 2026. Primary care physicians in Fresno, Kings, and Madera counties (Medi-Cal) should integrate eConsults into their workflow to access this incentive, which supports faster specialist access and reduces unnecessary referrals.
Medium impact
26-858 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination
Health Net·Identified Jul 21, 2026
HealthNet California is offering a limited-time financial incentive of $70 per eligible eConsult submitted and billed through ConferMED for primary care physicians in Imperial County, Medi-Cal. This incentive runs through October 1, 2026, with quarterly payments, requiring providers to ensure current W-9 information is on file with Provider Engagement.
Medium impact
26-859 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination
Health Net·Identified Jul 21, 2026
HealthNet California is offering a limited-time incentive of $70 per eligible eConsult submitted through ConferMED through October 1, 2026. Primary care physicians can earn quarterly payments by integrating eConsults into their workflow to improve specialist access and reduce referral delays. Practices must ensure current W-9 forms are on file with Provider Engagement to receive payments.
High impact
All Provider Bulletin 417: Continued Access to Care for MassHealth Members Transitioning from Managed Care to Fee-For-Service
MassHealth·Identified Jul 21, 2026
MassHealth members transitioning from managed care plans to fee-for-service (FFS) may continue seeing their current providers if they participate in MassHealth FFS. Prior authorization (PA) and pre-admission screening (PAS) approvals from managed care plans will be transferred to the FFS system, but providers will NOT receive notifications for these approvals. Billing teams must proactively verify PA/PAS status in the MassHealth Provider Online Service Center using the member's MassHealth ID before processing claims.
High impact
MAB2026072001
Pennsylvania Medicaid (DHS)·Effective Jul 20, 2026
Pennsylvania Medical Assistance (Medicaid) has issued new prior authorization guidelines for upper extremity prosthetics and components, effective immediately. All prescriptions for upper extremity prosthetics now require prior authorization with specific clinical documentation from rehabilitation specialists and prosthetists. Billing teams must implement these requirements for MA Fee-for-Service beneficiaries to avoid claim denials.
Low impact
Upcoming Notification of Pregnancy (NOP) and Risk Screening Webinar
Missouri Medicaid (MO HealthNet)·Identified Jul 21, 2026
The MO HealthNet Division is hosting a educational webinar on August 18, 2026, to train providers on the Notification of Pregnancy (NOP) and Risk Screening process. This is an informational session about an existing billing process, not a policy change requiring immediate workflow modifications. Providers are encouraged to register and review preparatory materials before the session.
Low impact
Find the latest medical policy updates in one place
AmeriHealth New Jersey·Identified Jul 21, 2026
AmeriHealth has published a centralized provider resource for accessing the latest medical policy updates. This is a general announcement directing providers to the AmeriHealth Provider News Center for ongoing policy changes rather than a specific policy change affecting billing or coverage.
Medium impact
Iqirvo® (elafibranor) (Revised)
Humana·Effective Sep 25, 2024
Humana Medicare Advantage updated its prior authorization policy for Iqirvo® (elafibranor) for Primary Biliary Cholangitis treatment. The policy requires prior authorization and establishes five specific clinical criteria that must be met, including documented PBC diagnosis, absence of complete biliary obstruction, no history of decompensated cirrhosis, prescriber requirement (gastroenterologist or hepatologist), and either ursodiol intolerance or inadequate response to one year of ursodiol therapy.
Medium impact
Duvyzat (givinostat) (Revised)
Humana·Effective Sep 25, 2024
Humana Medicare Advantage updated its prior authorization policy for Duvyzat (givinostat), a histone deacetylase inhibitor for Duchenne Muscular Dystrophy (DMD). The policy requires prior authorization before dispensing, with seven mandatory criteria for initial approval and two renewal criteria for continuation. Billing teams must ensure all prior auth requirements are met before claims are submitted to avoid denial.
Medium impact
Orladeyo (berotralstat) (Revised)
Humana·Effective Jan 1, 2025
This is a revised Humana prior authorization policy for Orladeyo (berotralstat) for hereditary angioedema (HAE) prophylaxis effective January 1, 2025, revised July 22, 2026. The policy applies to Medicare and Medicaid (South Carolina) and requires prior authorization with 8 specific clinical criteria, including HAE diagnosis confirmation via lab work, documentation of recurrent angioedema, specialist treatment, and prior trial/contraindication/intolerance to Haegarda. For Medicaid requests, step therapy requirements do not apply.
Medium impact
Kalbitor (ecallantide) (Revised)
Humana·Effective Jan 1, 2025
Humana has revised its prior authorization policy for Kalbitor (ecallantide) for treatment of acute hereditary angioedema (HAE) attacks effective January 1, 2025. The policy now applies to Medicare and Medicaid (Kentucky and South Carolina) and requires comprehensive documentation including HAE type confirmation, specific lab values (C4, C1INH levels, C1q), specialist treatment, and step therapy documentation (trial/contraindication/intolerance to generic icatibant) for coverage. Note: Medicaid members are exempt from step therapy requirements, while Medicare Part B members may be exempt if continuing prior therapy within 365 days.
Medium impact
Imfinzi (durvalumab) (Revised)
Humana·Effective Jan 1, 2025
Humana revised its Imfinzi (durvalumab) prior authorization policy effective January 1, 2025, covering 10 cancer indications across Medicare and three Medicaid states (Florida, Kentucky, South Carolina). The policy establishes specific clinical criteria, drug combination requirements, and exclusions for each indication. Key exclusion across most indications: disease progression on prior anti-PD-1/PD-L1 therapy disqualifies coverage. All approvals require prior authorization with 6-month initial and renewal periods.
Medium impact
Cinryze (C1 esterase inhibitor, human) (Revised)
Humana·Effective Jan 1, 2025
This is a revised Humana prior authorization policy for Cinryze (C1 esterase inhibitor) covering HAE prophylaxis in Medicare and Medicaid (Kentucky and South Carolina) members. The policy establishes 8 approval criteria including HAE Type 1/2 diagnosis confirmation, specific lab documentation (C4, C1INH levels, C1q level), history of recurrent angioedema, specialist treatment requirement, and—critically for Medicaid—NO step therapy requirement (meaning prior trial of Haegarda is NOT required for Medicaid requests, though it IS required for Medicare Part B).
High impact
Atezolizumab products (Tecentriq, Tecentriq Hybreza) (Revised)
Humana·Effective Jan 1, 2025
Humana revised its Atezolizumab (Tecentriq, Tecentriq Hybreza) pharmacy coverage policy effective January 1, 2025, with a revision date of July 22, 2026. This prior authorization policy covers eight cancer indications (advanced/metastatic NSCLC, bladder cancer, subsequent NSCLC, adjuvant NSCLC, small cell lung cancer, hepatocellular carcinoma, melanoma, and alveolar soft part sarcoma) across Medicare and three state Medicaid programs. Billing teams must verify prior authorization requirements and clinical criteria before processing claims for these oncology drugs.
Medium impact
Emrosi™ (minocycline) (Revised)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage has implemented a prior authorization requirement for Emrosi™ (minocycline 40mg extended-release) for rosacea treatment. Coverage now requires documented failure, intolerance, or contraindication with both topical metronidazole AND non-delayed release oral doxycycline before approval. This is a new pharmacy prior authorization policy effective July 23, 2025.
Medium impact
Andembry ® (garadacimab-gxii) (Revised)
Humana·Effective Jul 23, 2025
This is a revised Humana prior authorization policy for Andembry (garadacimab-gxii) for HAE prophylaxis in Medicare and Medicaid-South Carolina. The policy establishes 8 coverage criteria including HAE Type 1/2 diagnosis confirmation via specific lab values (C4, C1INH antigenic/functional levels, C1q level), documentation of recurrent angioedema without urticaria, treatment by a specialist, and a step-therapy requirement for Medicaid patients (trial or documented contraindication/intolerance to Haegarda). This is a pharmacy coverage policy requiring prior authorization before dispensing.
Medium impact
Amzeeq® (minocycline) Topical Foam (Revised)
Humana·Effective Jul 23, 2025
Humana Medicare Advantage has updated its prior authorization policy for Amzeeq® (minocycline) topical foam, effective July 23, 2025. The policy requires prior authorization for treating non-nodular moderate to severe acne vulgaris and mandates documented failure, intolerance, or contraindication with both a topical retinoid AND an oral non-delayed release tetracycline before approval.
Medium impact
Ekterly® (sebetralstat) (Revised)
Humana·Effective Aug 27, 2025
Humana has revised its prior authorization policy for Ekterly® (sebetralstat) for Medicaid in South Carolina, effective August 27, 2025. The policy establishes 8 mandatory criteria for coverage including HAE diagnosis confirmation, specific lab documentation (C4, C1INH levels, and C1q level), specialist treatment requirement, and prior trial/contraindication/intolerance to generic icatibant. For Medicaid requests, step therapy requirements do not apply.
Medium impact
Jevtana® (cabazitaxel) (Revised)
Humana·Effective Sep 1, 2025
This is a revised Humana Medicaid (Indiana) prior authorization policy for Jevtana® (cabazitaxel) for hormone-refractory metastatic prostate cancer. The policy requires prior authorization and specifies three mandatory approval criteria: hormone-refractory metastatic prostate cancer diagnosis, prior docetaxel treatment, and concurrent corticosteroid use. Three exclusions apply: neutrophil counts ≤1,500/mm³, severe hepatic impairment (bilirubin >3x ULN), and concomitant use with abiraterone acetate, Yonsa, or Xtandi.
Medium impact
Jevtana® (cabazitaxel) (Revised)
Humana·Effective Sep 1, 2025
Humana Medicaid (Louisiana) has revised its Jevtana (cabazitaxel) prior authorization policy effective September 1, 2025. The policy requires prior authorization for this intravenous chemotherapy drug and mandates three specific approval criteria: (1) diagnosis of hormone-refractory metastatic prostate cancer, (2) prior docetaxel treatment, and (3) concurrent corticosteroid use. Three key exclusions prohibit use in patients with neutrophils ≤1,500/mm³, hepatic impairment (total bilirubin >3× ULN), or concomitant use with abiraterone acetate, Yonsa, or Xtandi.
Medium impact
Jevtana® (cabazitaxel) (Revised)
Humana·Effective Sep 1, 2025
This is a revised Humana Medicaid (Ohio) prior authorization policy for Jevtana® (cabazitaxel) effective September 1, 2025, most recently updated July 22, 2026. The policy requires prior authorization for Jevtana use in hormone-refractory metastatic prostate cancer patients who have previously received docetaxel and are concurrently taking corticosteroids. Billing teams must verify three mandatory criteria and screen for three exclusions (neutrophil count ≤1,500/mm³, hepatic impairment with bilirubin >3x ULN, and concomitant use with abiraterone or enzalutamide) before submitting claims.

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Archive by year

2023 2024 2025 2026

ICF Quarterly Webinar with HHSC LTCR

Updated OASIS Training Opportunity for Licensed and Certified Home Health Agencies

Providers Must Have a Valid Email Address on Record to Access TMHP Applications Through TMHP IAMOnline

IAMOnline Educational Video Now Available

26-857 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination

26-858 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination

26-859 Earn $70 Per eConsult – Improve Specialist Access and Care Coordination

All Provider Bulletin 417: Continued Access to Care for MassHealth Members Transitioning from Managed Care to Fee-For-Service

MAB2026072001

Upcoming Notification of Pregnancy (NOP) and Risk Screening Webinar

Find the latest medical policy updates in one place

Iqirvo® (elafibranor) (Revised)

Duvyzat (givinostat) (Revised)

Orladeyo (berotralstat) (Revised)

Kalbitor (ecallantide) (Revised)

Imfinzi (durvalumab) (Revised)

Cinryze (C1 esterase inhibitor, human) (Revised)

Atezolizumab products (Tecentriq, Tecentriq Hybreza) (Revised)

Emrosi™ (minocycline) (Revised)

Andembry ® (garadacimab-gxii) (Revised)

Amzeeq® (minocycline) Topical Foam (Revised)

Ekterly® (sebetralstat) (Revised)

Jevtana® (cabazitaxel) (Revised)

Jevtana® (cabazitaxel) (Revised)

Jevtana® (cabazitaxel) (Revised)