All Insurance Policy Changes (Page 87)

Continuing from page 86. 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
Idursulfase (Elaprase®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Idursulfase (Elaprase®) for treatment of Hunter syndrome (Mucopolysaccharidosis II, MPS II) effective 9/30/2026. The policy establishes coverage criteria requiring confirmed enzyme deficiency diagnosis, clinical disease symptoms at baseline, specialist prescription, and documented clinical response for continuation therapy. Prior authorization is required with specific documentation including diagnostic confirmation and disease progression monitoring.
High impact
Histrelin Acetate (Supprelin®LA)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has released a new medical policy for Histrelin Acetate (Supprelin LA) covering four indications: central precocious puberty (FDA-approved), gender dysphoria, preservation of ovarian function, and prevention of recurrent menstrual-related attacks in acute porphyria (all compendial uses). The policy establishes specific prior authorization requirements, documentation standards, prescriber specialty restrictions, and coverage criteria for each indication. DO NOT IMPLEMENT until 9/30/26.
Medium impact
Galsulfase (Naglazyme®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has established a new prior authorization policy for Galsulfase (Naglazyme®) effective 9/30/2026. Coverage is limited to FDA-approved indication of Mucopolysaccharidosis VI (MPS VI) when diagnosis is confirmed by enzyme assay or genetic testing and clinical symptoms are documented. Initial authorization is for 12 months; continuation requires documented clinical response (improvement, stabilization, or slowing of disease progression). All prescriptions must be from or in consultation with a metabolic disease or lysosomal storage disorder specialist.
High impact
Fam-trastuzumab Deruxtecan-nxki (Enhertu®)
BCBS Tennessee·Effective Sep 30, 2026
This is a NEW medical policy for Fam-trastuzumab Deruxtecan-nxki (Enhertu®) covering multiple cancer indications including HER2-positive breast cancer, HER2-low/ultralow breast cancer, HER2-mutant NSCLC, gastric cancer, and other solid tumors. The policy establishes coverage criteria, prior authorization requirements, and documentation needs. CRITICAL: This policy is marked 'Do Not Implement until 9/30/26' — it is not yet active.
Medium impact
Eribulin Mesylate (Halaven®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has released a new prior authorization policy for Eribulin Mesylate (Halaven®) effective September 30, 2026, establishing coverage criteria for metastatic breast cancer and soft tissue sarcoma with specific HER2-status documentation requirements and 12-month authorization limits. This is a NEW policy establishing medical necessity guidelines and prior auth requirements for this chemotherapy agent.
Medium impact
Epcoritamab-bysp (Epkinly™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is introducing a new medical policy for Epcoritamab-bysp (Epkinly™), a bispecific antibody for relapsed/refractory B-cell lymphomas and follicular lymphoma. The policy establishes coverage criteria requiring prior authorization for specific indications and treatment combinations, with a maximum 12-month authorization period. This policy will NOT take effect until September 30, 2026.
High impact
Durvalumab (Imfinzi®)
BCBS Tennessee·Effective Sep 30, 2026
This is a new medical policy establishing coverage criteria and prior authorization requirements for Durvalumab (Imfinzi®) across multiple cancer indications including NSCLC, SCLC, biliary tract, hepatocellular carcinoma, endometrial, bladder, and gastric cancers. The policy specifies required genetic/molecular testing documentation, treatment combinations, disease stages, and 6-month authorization periods. CRITICAL: This policy is marked 'Do Not Implement until 9/30/26' and is not yet effective.
Medium impact
Datopotamab Deruxtecan-dlnk (Datroway®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Datopotamab Deruxtecan-dlnk (Datroway®), a newly FDA-approved cancer treatment. The policy covers HR-positive/HER2-negative metastatic breast cancer and EGFR-mutated NSCLC with specific prior treatment requirements. Authorization is limited to 12 months per approval with reauthorization available for continuation. Policy takes effect September 30, 2026.
Medium impact
Cipaglucosidase Alfa-atga (Pombiliti™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Cipaglucosidase Alfa-atga (Pombiliti) in combination with Opfolda for treatment of late-onset Pompe disease in adults ≥40 kg who are not improving on current enzyme replacement therapy. The policy requires specialist consultation, specific diagnostic confirmation, and documented clinical signs/symptoms. Initial authorization grants 12 months; continuation requires documented therapeutic response.
Medium impact
Beremagene Geperpavec-svdt (Vyjuvek™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new coverage policy for Beremagene Geperpavec-svdt (Vyjuvek™), a gene therapy for dystrophic epidermolysis bullosa (DEB) with COL7A1 gene mutations. The policy requires prior authorization, genetic testing confirmation, dermatologist or wound care specialist prescription, and specific wound criteria before coverage is granted for up to 12 months of weekly treatment.
Medium impact
Belimumab (Benlysta®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Belimumab (Benlysta®) effective September 30, 2026, covering treatment of active systemic lupus erythematosus (SLE) and active lupus nephritis in patients 5 years and older. Coverage requires prior authorization, specific autoantibody testing, concurrent standard therapy, and prescriber specialty validation (rheumatology/nephrology). The policy excludes severe active CNS lupus and concurrent biologic use.
Medium impact
Azacitidine (Vidaza®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Azacitidine (Vidaza®) effective 9/30/2026 establishing coverage criteria for six oncologic indications: myelodysplastic syndromes (MDS), acute myeloid leukemia (AML), accelerated/blast phase myeloproliferative neoplasm, blastic plasmacytoid dendritic cell neoplasm (BPDCN), MDS/MPN overlap neoplasms, and peripheral T-cell lymphoma (PTCL). All covered indications require prior authorization for 12-month periods, with continuation therapy authorized upon reauthorization if no unacceptable toxicity or disease progression occurs. DO NOT IMPLEMENT until 9/30/26.
High impact
Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)
BCBS Tennessee·Effective Sep 30, 2026
This is a NEW medical policy for Tecentriq Hybreza™ (atezolizumab and hyaluronidase-tqjs), an immunotherapy drug covering multiple cancer indications including NSCLC, SCLC, HCC, melanoma, and others. The policy establishes prior authorization requirements, coverage criteria, and required documentation (including PD-L1 expression testing, genetic mutation testing, and tumor profiling). All authorizations are limited to 6-month intervals. DO NOT implement until September 30, 2026.
High impact
Atezolizumab (Tecentriq®)
BCBS Tennessee·Effective Sep 30, 2026
This is a new comprehensive medical policy for Atezolizumab (Tecentriq®) that establishes coverage criteria, prior authorization requirements, and documentation standards across multiple cancer indications including NSCLC, SCLC, HCC, melanoma, mesothelioma, and others. The policy requires prior authorization with specific genetic/molecular testing documentation and grants 6-month authorization periods for covered indications. Do NOT implement until 9/30/26.
Medium impact
Anifrolumab-fnia (Saphnelo®)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is introducing a new medical policy for Anifrolumab-fnia (Saphnelo®), a biologic treatment for moderate to severe systemic lupus erythematosus (SLE) in adults. The policy establishes coverage criteria requiring prior authorization, specific documentation of autoantibodies, concurrent standard SLE therapy, rheumatologist prescribing, and exclusions for severe lupus nephritis and CNS lupus. This policy becomes effective September 30, 2026, and applies to Tennessee members.
High impact
Verifying Eligibility for MO HealthNet Participants and Managed Care Members
Missouri Medicaid (MO HealthNet)·Effective Jul 16, 2026
MO HealthNet has issued mandatory eligibility verification requirements effective immediately. Providers must verify participant eligibility before every visit using real-time verification methods (eMOMED system, phone, or batch submission) and confirm active eligibility on the exact date of service. This applies to both Fee-For-Service participants and Managed Care members, with an additional requirement to verify with the specific Managed Care health plan for MC members.
High impact
Pediatric and Primary Care Providers: New Process for Prescribing Specialized Formulas
Missouri Medicaid (MO HealthNet)·Effective Jul 1, 2026
Effective July 1, 2026, MO HealthNet (Missouri Medicaid) becomes the primary payer for medically necessary specialized infant formulas (elemental, amino-acid based, metabolic formulas), replacing the WIC program. Providers must now send specialized formula prescriptions to MO HealthNet-enrolled DME providers instead of WIC clinics. WIC transitions to secondary payer and safety-net role only.
Medium impact
Compounded Medications (Revised)
Humana·Effective Jul 23, 2025
Humana revised its compounded medication coverage policy for Medicare Advantage plans, effective July 23, 2025. Compounded medications are now covered only if they meet Part D drug definitions with compendia support, reject with specific error codes (307 or 524), and contain no experimental/investigational ingredients. Billing teams must implement claims review procedures to ensure compounded medications comply with compendia-supported indications and dosage forms before submission.
Medium impact
Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)
Humana·Identified Jul 17, 2026
Medicare Advantage has revised its genetic testing policy to cover DNA analysis for diagnosing inherited conditions in symptomatic patients. The policy permits genetic testing to confirm diagnoses and guide treatment decisions for conditions including achondroplasia, alpha-1 antitrypsin deficiency, Barth syndrome, cardiofaciocutaneous syndrome, celiac disease, Charcot-Marie-Tooth disease, and epidermolysis bullosa, among others.
Medium impact
Pharmacogenomics Testing - MEDICAID - SOUTH CAROLINA (Revised)
Humana·Effective Jul 22, 2026
Humana Medicaid in South Carolina updated its pharmacogenomics testing coverage policy, effective July 22, 2026. The policy now covers ChemoFx Assay (CPT 81535/81536) for gynecologic cancers meeting specific clinical criteria, and molecular pathology testing (CPT 81479) for patients on medications with FDA-labeled or CPIC Level A/B gene-drug interactions. For members under 21, all requests require medical necessity review under EPSDT requirements.
Medium impact
Pharmacogenomics Testing - MEDICAID - MICHIGAN (New)
Humana·Effective Jul 22, 2026
Humana Michigan Medicaid now covers pharmacogenomics testing (CPT 81479) for patients on medications with known gene-drug interactions per FDA labeling or CPIC guidelines (level A or B). However, ChemoFx Assay (CPT 81535/81536) and SLCO1B1 genotype testing (CPT 81328) are explicitly NOT covered due to insufficient evidence. Billing teams must verify drug-gene interaction documentation before submitting claims and deny or reject claims for the two excluded test codes.
Medium impact
Pharmacogenomics Testing - MEDICAID - INDIANA (Revised)
Humana·Effective Jul 22, 2026
Humana Indiana Medicaid updated its pharmacogenomics testing coverage policy effective 07/22/2026. The policy covers molecular pathology testing (CPT 81479) for pharmacogenomics analysis when treating with medications having known gene-drug interactions per FDA labeling or CPIC guidelines (Level A or B), and covers SLCO1B1 genotype testing (CPT 81328) for statin-induced myopathy risk assessment. For members under age 21, testing requires medical necessity review under EPSDT requirements.
High impact
Medicaid Hospital Inpatient Billing Discharge Status Codes
EmblemHealth·Identified Jul 17, 2026
EmblemHealth has issued an urgent reminder for in-network hospitals to correctly identify and code patient discharge status (transfer vs. discharge) on Medicaid hospital inpatient claims, as improper coding directly affects reimbursement. Billing teams must ensure accurate status code assignment per the referenced Medicaid Update guidance to avoid claim denials and payment delays.
High impact
New and Updated Reimbursement Policies
EmblemHealth·Effective Jul 15, 2026
EmblemHealth is implementing new reimbursement criteria for inpatient facility transfers under commercial contracts effective July 15, 2026. Transferring facilities will no longer receive payment for the discharge/transfer day, no outlier payments will be allowed under per diem methodology, and same-day transfers (within 24 hours) will not be reimbursed. A separate policy applies to Medicare/Medicaid transfers.
Medium impact
Updated Preauthorization Lists
EmblemHealth·Effective Aug 13, 2026
EmblemHealth has updated its Preauthorization Lists effective August 13, 2026. The policy references a Pharmacy Preauthorization List (JP71452, dated 05/2026) and notes no new quarterly AMA/CMS code updates for April. Billing teams must consult the revision history for specific updates and effective dates on the referenced preauthorization list.

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Archive by year

2023 2024 2025 2026

Idursulfase (Elaprase®)

Histrelin Acetate (Supprelin®LA)

Galsulfase (Naglazyme®)

Fam-trastuzumab Deruxtecan-nxki (Enhertu®)

Eribulin Mesylate (Halaven®)

Epcoritamab-bysp (Epkinly™)

Durvalumab (Imfinzi®)

Datopotamab Deruxtecan-dlnk (Datroway®)

Cipaglucosidase Alfa-atga (Pombiliti™)

Beremagene Geperpavec-svdt (Vyjuvek™)

Belimumab (Benlysta®)

Azacitidine (Vidaza®)

Atezolizumab and Hyaluronidase-tqjs (Tecentriq Hybreza™)

Atezolizumab (Tecentriq®)

Anifrolumab-fnia (Saphnelo®)

Verifying Eligibility for MO HealthNet Participants and Managed Care Members

Pediatric and Primary Care Providers: New Process for Prescribing Specialized Formulas

Compounded Medications (Revised)

Genetic Testing for Diagnosis of Inherited Conditions - Medicare Advantage (Revised)

Pharmacogenomics Testing - MEDICAID - SOUTH CAROLINA (Revised)

Pharmacogenomics Testing - MEDICAID - MICHIGAN (New)

Pharmacogenomics Testing - MEDICAID - INDIANA (Revised)

Medicaid Hospital Inpatient Billing Discharge Status Codes

New and Updated Reimbursement Policies

Updated Preauthorization Lists