All Insurance Policy Changes (Page 83)

Continuing from page 82. 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
Pennsaid (diclofenac topical solution) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has updated its Pennsaid (diclofenac topical solution) pharmacy coverage policy, effective January 1, 2026, with a revision dated July 22, 2026. The policy requires prior authorization for all diclofenac topical formulations (brand Pennsaid and generic) when treating osteoarthritis of the knee. Coverage is limited to members with a documented diagnosis of osteoarthritis of the knee(s), approved for the initial and renewal plan year duration.
Medium impact
Nonsteroidal Anti-Inflammatory Drug Products (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare implemented a revised step therapy policy for NSAID products effective January 1, 2026 (updated July 22, 2026). The policy requires members to have documented prior treatment with at least TWO generic NSAIDs (diclofenac, ibuprofen, meloxicam, celecoxib, or naproxen) within the past 12 months before approval for brand-name or specialty NSAID formulations. The policy also reinforces cardiovascular and gastrointestinal contraindications and pregnancy warnings.
High impact
IVIG (immune globulin) (Revised)
Humana·Effective Jan 1, 2026
Humana revised its IVIG (immune globulin) pharmacy coverage policy effective January 1, 2026, with updates as of July 22, 2026. The policy clarifies prior authorization requirements, preferred product selections, and clinical criteria for coverage across 24 IVIG formulations for Medicare and Medicaid (Kentucky and South Carolina) members. Key requirements include step therapy with preferred products unless prior therapy/intolerance documented, specific clinical thresholds (e.g., IgG levels, platelet counts), and condition-specific approval criteria for 22 listed indications.
Medium impact
Elrexfio (elranatamab-bcmm) (Revised)
Humana·Effective Jan 1, 2026
This is a revised prior authorization policy for Elrexfio (elranatamab-bcmm), a bispecific BCMA-directed CD3 T-cell engager for relapsed/refractory multiple myeloma in Louisiana Medicaid members. The policy requires prior authorization and mandates that members have received at least four prior lines of therapy (including specific drug classes) and are using Elrexfio as a single agent. Members with prior disease progression on BCMA-directed regimens are excluded.
High impact
Asthma Interleukin Inhibitors (Cinqair®, Nucala™, Fasenra®) (Revised)
Humana·Effective Jan 1, 2026
This is a revised Medicare Advantage prior authorization policy for asthma interleukin inhibitors (Cinqair, Nucala, Fasenra) effective January 1, 2026, with updates as of July 22, 2026. The policy establishes specific clinical criteria for coverage across five indications: severe eosinophilic asthma, EGPA, HES, chronic rhinosinusitis with nasal polyposis, and eosinophilic COPD. Billing teams must verify all prior authorization requirements before dispensing these specialty medications.
Medium impact
Oncaspar® (pegaspargase) (Revised)
Humana·Effective Jul 22, 2026
Humana Indiana Medicaid revised its Oncaspar (pegaspargase) coverage policy, effective July 22, 2026. This is a prior authorization requirement for pegaspargase used in multi-agent chemotherapy regimens for acute lymphoblastic leukemia (ALL). The policy includes specific approval criteria, exclusions based on prior adverse events, and a 6-month initial and renewal authorization period.
Medium impact
Oncaspar® (pegaspargase) (Revised)
Humana·Effective Feb 1, 2026
Humana Medicaid Louisiana revised its Oncaspar (pegaspargase) coverage policy effective February 1, 2026, with updates as of July 22, 2026. This is a Prior Authorization policy for pegaspargase used in acute lymphoblastic leukemia (ALL) treatment. Coverage requires diagnosis of ALL and use as part of multi-agent chemotherapy, with specific exclusions for disease progression, prior thrombosis, pancreatitis, hemorrhagic events, or elevated bilirubin levels.
Medium impact
Oncaspar® (pegaspargase) (Revised)
Humana·Effective Feb 1, 2026
Humana Medicaid-Ohio has revised its Oncaspar (pegaspargase) prior authorization policy, effective February 1, 2026, with the most recent revision dated July 22, 2026. This is a pharmacy coverage policy requiring prior authorization for pegaspargase use in acute lymphoblastic leukemia (ALL) patients as part of multi-agent chemotherapy. The policy establishes specific approval criteria, exclusion criteria (including prior serious thrombosis, pancreatitis, or hemorrhagic events with asparaginase therapy), and a 6-month initial and renewal approval duration.
Medium impact
Adzynma (ADAMTS13, recombinant-krhn) (Revised)
Humana·Effective Feb 1, 2026
This is a new Medicaid (Indiana) prior authorization policy for Adzynma (ADAMTS13, recombinant-krhn), effective February 1, 2026, with a revision date of July 22, 2026. The policy establishes coverage criteria for this enzyme replacement therapy in patients with congenital thrombotic thrombocytopenic purpura (cTTP), requiring confirmation of diagnosis, ADAMTS13 activity levels, genetic testing, and negative antibody testing. Billing teams must implement prior authorization workflows and ensure providers submit required diagnostic documentation before dispensing.
Medium impact
Adzynma (ADAMTS13, recombinant-krhn) (Revised)
Humana·Effective Feb 1, 2026
This is a new Medicaid (Ohio) prior authorization policy for Adzynma (ADAMTS13, recombinant-krhn), effective February 1, 2026, with a revision dated July 22, 2026. The policy establishes coverage criteria for this enzyme replacement therapy in adult and pediatric patients with congenital thrombotic thrombocytopenic purpura (cTTP), requiring prior authorization and confirmation of diagnosis through plasma ADAMTS13 activity testing, molecular genetic testing, and antibody screening before approval.
Medium impact
Lifyorli (relacorilant) (Revised)
Humana·Effective May 27, 2026
Humana Medicare Advantage has revised its prior authorization policy for Lifyorli (relacorilant), a glucocorticoid receptor antagonist used in combination with nab-paclitaxel for platinum-resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer. The policy requires prior authorization and specifies strict criteria including platinum-resistant disease diagnosis, combination use with nab-paclitaxel, and prior treatment history (1-3 prior systemic therapy lines with at least one including bevacizumab). This is a revision to an existing policy effective May 27, 2026.
Medium impact
Clinical Trials - MEDICAID - LOUISIANA (Revised)
Humana·Effective Jul 20, 2026
This is a NEW Medicaid clinical trials coverage policy for Louisiana (Humana Healthy Horizons) effective 07/20/2026. The policy establishes coverage for items and services provided to members participating in qualifying clinical trials, with expedited 72-hour coverage determinations, no geographic/network restrictions, and specific criteria for trial qualification (NIH/CDC/CMS support, peer-reviewed, or investigational drug exemption status). Billing teams must understand coverage limitations: investigational items themselves are NOT covered, data collection-only services are NOT covered, and only services otherwise covered by the plan are eligible.
Medium impact
Pharmacogenomics Testing - MEDICAID - VIRGINIA (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid (Virginia) has revised its pharmacogenomics testing coverage policy effective 07/22/2026. The policy now covers molecular pathology testing (CPT 81479) for pharmacogenomics analysis when patients are being treated with or considered for medications with known FDA-labeled or CPIC guideline level A/B gene-drug interactions. A specific list of 17 branded pharmacogenomics tests are explicitly non-covered due to insufficient evidence.
Medium impact
Neurostimulators - MEDICAID - KENTUCKY (New)
Humana·Effective Jul 22, 2026
Humana Kentucky Medicaid has established a new coverage policy for intracranial neurostimulator electrodes, effective 07/22/2026. The policy covers implantation of cerebral/cortical neurostimulator electrodes (CPT 61850, 61860) and removal/revision procedures (CPT 61880) when medically necessary. Prior authorization is required for all covered procedures. For members under age 21, requests must meet EPSDT requirements.
Medium impact
Multi-Function Oscillation Lung Expansion Therapy - MEDICAID - VIRGINIA (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid Virginia has clarified that Multi-Function Oscillation Lung Expansion (OLE) therapy devices, including BiWaze Clear System and Volara System (HCPCS E0469), are NOT covered for any indication due to insufficient clinical evidence. This is a non-coverage determination effective 07/22/2026. Billing teams must deny all claims for this service and educate providers that requests will be consistently denied under this plan.
High impact
Mobility Assistive Devices (Wheelchairs) - MEDICAID - KENTUCKY (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid Kentucky revised its coverage policy for mobility assistive devices (wheelchairs) effective 07/22/2026. The policy requires prior authorization for all wheelchair requests and establishes specific medical necessity criteria for power wheelchairs, manual wheelchairs, scooters, and accessories. Billing teams must ensure all wheelchair claims include required prior authorization, home assessments for power wheelchairs, and specialty evaluations for complex rehabilitation devices.
Medium impact
Lynavoy (linerixibat) (New)
Humana·Effective Jul 22, 2026
Humana Medicare Advantage has established a new prior authorization policy for Lynavoy (linerixibat), effective July 22, 2026. The drug is approved only for patients with primary biliary cholangitis (PBC) experiencing moderate to severe cholestatic pruritus who are stable on maintenance PBC therapy and have failed or cannot tolerate at least two alternative treatments (cholestyramine, rifampin, or naltrexone). Claims must meet all five clinical criteria or they will be denied.
Medium impact
Excessive Skin and Subcutaneous Tissue Removal - MEDICAID - KENTUCKY (New)
Humana·Effective Jul 22, 2026
Humana Kentucky Medicaid has established new coverage criteria for excessive skin and subcutaneous tissue removal procedures. Coverage now requires: (1) functional impairment from excess skin/tissue, (2) medical complications unrelieved by 12+ weeks of prescribed dermatological therapy, and (3) stable body weight maintained for 6+ months. Prior authorization is mandatory for all applicable procedures. This is a NEW policy effective 07/22/2026.
High impact
PDF Version
Molina Healthcare·Effective Apr 1, 2026
Molina Care Connections expands telehealth and in-person nurse practitioner services across 22 states with open scheduling for preventive care and chronic condition management. Developmental screening requirements for children ages 1-3 now mandate use of standardized global screening tools (CPT 96110) with specific documentation; domain-specific tools (M-CHAT, ASQ:SE) are no longer billable for this measure. Utilization management criteria and processes remain unchanged but are clarified for provider reference.
Low impact
Attention All Providers: Nevada Medicaid Adds Behaviorally Complex Care Program (BCCP) Tier Level Details to Eligibility
Nevada Medicaid·Effective Jul 20, 2026
Nevada Medicaid has added a new BCCP Tier Level Details section to the Provider Web Portal and 271 eligibility responses, effective July 20, 2026. Providers can now view member BCCP tier assignments (Tier 1, 2, or 3) along with effective and end dates in the Coverage Details section. This is view-only informational data reflecting behavioral complexity levels for applicable members.
High impact
Web Announcement 3964
Nevada Medicaid·Effective Jul 20, 2026
Nevada Medicaid has released the top 10 claim denial reasons for June 2026 professional claims with specific error codes and resolution steps. This announcement identifies common billing and enrollment issues (provider termination, invalid contracts, enrollment status, modifier disputes, and TPL problems) and provides actionable workarounds for each. Billing teams must implement preventive measures to reduce denials by verifying provider enrollment status, contract dates, linkage information, and claim details before submission.
Medium impact
Cigna Providers Outside a Kaiser Permanente State (Outside CA, CO, DC, GA, HI, MD, OR, VA, WA)
Kaiser Permanente·Identified Jul 21, 2026
Kaiser Permanente members with HMO, EPO, POS, and PPO plans traveling outside Kaiser Permanente states (CA, CO, DC, GA, HI, MD, OR, VA, WA) now have access to emergency, urgent, and covered services through Cigna Healthcare's PPO network at negotiated rates. Cigna PPO network providers outside KP states should collect applicable cost-sharing only from eligible KP 3-Tier POS and KPIC PPO members at time of service; other eligible members require no upfront payment until claims are processed.
Low impact
National Provider Contracting and Strategy*
Kaiser Permanente·Identified Jul 21, 2026
This policy document is a landing page for Kaiser Permanente's National Provider Contracting and Strategy program that provides general information about provider resources, online tools, and support services. It does not contain specific billing, coding, coverage, or operational policy changes that would directly impact medical billing workflows.
Medium impact
BH Outpatient Update: Electronic Auth Extensions Now Available
Highmark·Effective Jul 20, 2026
Highmark now allows behavioral health outpatient therapy authorization extensions to be requested electronically through Availity Essentials via Predictal, eliminating the need for faxes or phone calls. This streamlines the prior authorization extension process for providers but does not change coverage policies or eligibility criteria. Denied authorizations remain ineligible for extensions.
Medium impact
Formulary Policy Updates
MVP Health Care·Identified Jul 19, 2026
MVP Health Care has updated its Q2 2025 formulary, removing prior authorization requirements for Ojemda (tablet and suspension), excluding four new drugs (Duvyzat, Iqirvo, Myhibbin, Tyenne, Tofidence) from coverage, and adding two new generic medications (Octreotide IM injection and Hydrocortisone succinate PF) to the formulary. Changes take effect on each member's plan year start date.

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Insurance Policy Changes Tracker: All Payer Updates (Page 83) | PolicyChanges.app

Pennsaid (diclofenac topical solution) (Revised)

Nonsteroidal Anti-Inflammatory Drug Products (Revised)

IVIG (immune globulin) (Revised)

Elrexfio (elranatamab-bcmm) (Revised)

Asthma Interleukin Inhibitors (Cinqair®, Nucala™, Fasenra®) (Revised)

Oncaspar® (pegaspargase) (Revised)

Oncaspar® (pegaspargase) (Revised)

Oncaspar® (pegaspargase) (Revised)

Adzynma (ADAMTS13, recombinant-krhn) (Revised)

Adzynma (ADAMTS13, recombinant-krhn) (Revised)

Lifyorli (relacorilant) (Revised)

Clinical Trials - MEDICAID - LOUISIANA (Revised)

Pharmacogenomics Testing - MEDICAID - VIRGINIA (Revised)

Neurostimulators - MEDICAID - KENTUCKY (New)

Multi-Function Oscillation Lung Expansion Therapy - MEDICAID - VIRGINIA (Revised)

Mobility Assistive Devices (Wheelchairs) - MEDICAID - KENTUCKY (Revised)

Lynavoy (linerixibat) (New)

Excessive Skin and Subcutaneous Tissue Removal - MEDICAID - KENTUCKY (New)

PDF Version

Attention All Providers: Nevada Medicaid Adds Behaviorally Complex Care Program (BCCP) Tier Level Details to Eligibility

Web Announcement 3964

Cigna Providers Outside a Kaiser Permanente State (Outside CA, CO, DC, GA, HI, MD, OR, VA, WA)

National Provider Contracting and Strategy*

BH Outpatient Update: Electronic Auth Extensions Now Available

Formulary Policy Updates