February 2026 Drug List Change Notification (Commercial)
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Insurance Policy Changes in 2025
All insurance policy changes we tracked in 2025. Each entry is AI-summarized with an impact rating and linked billing codes so you can quickly assess what matters to your practice. Showing the 50 most recent of 145 total changes for 2025.
Upcoming Changes to Prior Authorization Process for Physician-Administered Drugs – Effective January 1, 2026
Arkansas Medicaid is transferring physician-administered drug (PAD) prior authorization processing from AFMC to Prime Therapeutics effective January 1, 2026. Providers must submit PAD PA requests electronically through CoverMyMeds or by fax to Prime Therapeutics. Additionally, any modifications to existing PAs will now require new PA numbers instead of allowing modifications under the same PA number.
Thank You for Your Care and Commitment
This is a year-end thank you message from Highmark highlighting recent improvements including expanded Gold Carding Program, new Communications Hub, monthly onboarding webinars, and Provider Chat for Pennsylvania. No billing code or coverage changes are announced.
When a natural disaster strikes, Regence is here to support your care needs
Regence has implemented emergency pharmacy access policies for members affected by flooding in declared disaster areas. During officially declared emergencies, members may refill prescriptions at any pharmacy (waiving network restrictions) and receive emergency care at in-network rates. This is a temporary, disaster-response policy effective immediately for affected regions.
Bennett Lumber maintains a dedicated workforce with help from Regence health plans
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January 2026 Community Solutions (Medicaid) formulary and coverage policies notification
PacificSource Community Solutions (Medicaid) removed three medications from formulary effective January 15, 2026: Xifaxan, Actемra ACTpen, and Actемra prefilled syringe. Billing teams must identify claims for these drugs and implement denial protocols or alternative medication routing for affected Medicaid members.
Prior authorization changes for February 1, 2026 – Medicare and Medicaid
Effective February 1, 2026, PacificSource is implementing new prior authorization requirements for Medicare and Medicaid. Medicare adds 20 procedure codes requiring prior auth (including arthroscopy, unlisted procedures, and specialized diagnostics) plus 3 codes requiring prior auth only when claims exceed $500. Medicaid adds 2 codes requiring prior auth. Billing teams must update systems and verify all affected codes before service delivery to avoid claim denials.
Prior Authorization Submission Help and Tips
Highmark has implemented a new prior authorization submission process requiring all medical prior auth requests to be submitted through Availity Essentials via the Authorizations and Referrals workflow, not via fax or Predictal. The system has been updated to eliminate confusion and streamline the workflow with specific buttons and processes that must be followed.
Our health plans’ coverage of hepatitis B vaccinations remains unchanged
This is a clarification that plan coverage for hepatitis B vaccinations remains unchanged despite new CDC ACIP recommendations (effective December 5, 2025) that limit the birth dose to infants whose mothers are hepatitis B positive or have unknown status. Plans continue to cover hepatitis B and all preventive vaccines at 100% with no member cost-sharing, regardless of administration timing.
Authorization Updates - Effective Dec 2025, Jan 2026, and Mar 2026
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Coverage for Home Sleep Study (Proc Codes 95800, 95801, and 95806)
Arkansas Department of Human Services (DHS) added coverage for home sleep studies (CPT 95800, 95801, 95806) effective November 14, 2025, for patients 16+ years at high risk for obstructive sleep apnea. The policy establishes medical necessity criteria, requires certification standards for technologists/specialists, and includes specific reimbursement rates by procedure code and modifier.
Continued access to care through St. Charles & Salem Health for Commercial and Medicare Members
PacificSource has secured continued in-network agreements with St. Charles Health System and Salem Health Hospitals & Clinics for Commercial and Medicare plans in 2026 (and 2027 for St. Charles Commercial). No coverage or provider access changes for Commercial and Medicare members—billing teams should take no action as claims processing workflow remains unchanged. Note: Medicaid coverage with Salem Health is still under negotiation.
Rib Remodeling and Clavicle Shortening (BSC7.21)
Blue Shield of California medical policy BSC7.21 addresses rib remodeling and clavicle shortening for body contouring. Rib remodeling for body contouring, including WASP, RIBOSS, RibXcar and UUAIST, is considered investigational. Clavicle shortening for body contouring is also considered investigational. The policy was first issued December 1, 2025, and its March 1, 2026 version includes an administrative update and a coding update.
Special Alert December 2025 - Taxonomy Requirements
Effective March 15, 2026, Providence Health Plan (PHP) and Providence Health Assurance (PHA) will require taxonomy codes on all provider-submitted Medicare and Commercial claims. Claims submitted with missing or incorrect taxonomy codes will be denied. Providers must ensure their taxonomy codes are registered with CMS and included in all claim submissions.
Whole Exome and Whole Genome Sequencing for Diagnosis of Genetic Disorders (2.04.102)
Blue Shield of California medical policy 2.04.102 has been in effect since April 1, 2026, and its policy statement did not change in this annual review, which updated the guidelines, literature review and coding. Standard whole exome sequencing (with trio testing when possible) may be considered medically necessary for unexplained congenital or neurodevelopmental disorders, and standard whole genome sequencing may be considered medically necessary for these disorders in children, when the policy criteria are met. Rapid WES or rapid WGS may be considered medically necessary for critically ill infants in neonatal or pediatric intensive care with a suspected genetic disorder of unknown etiology when the policy criteria are met, while repeat WES (including re-analysis), screening, and all other uses of WES or WGS are considered investigational.
Medica Provider News: December 2025
Effective January 1, 2026, several products move to payer ID 71890, and members receive new member ID cards with payer ID 71890, a newly assigned group/policy number, and a new member ID number. Effective November 1, 2025, coverage for adalimumab products changed for commercial and IFB members, so the Simlandi and Hadlima medications no longer have coverage while their biosimilar alternatives are covered on the same tier with a quantity limit and prior authorization. Practitioners who do not respond to recredentialing requests will be administratively terminated after exceeding the 36-month recredentialing cycle.
Identification of Microorganisms Using Nucleic Acid Probes (2.04.10)
Blue Shield of California medical policy 2.04.10, Identification of Microorganisms Using Nucleic Acid Probes, has an effective date of October 1, 2026, and its policy statement has no changes from the previous version. Nucleic acid testing without quantification of viral load may be considered medically necessary for listed organisms, including Chlamydia trachomatis, Neisseria gonorrhoeae, influenza virus, SARS-CoV-2, and Streptococcus group A and group B, while testing with quantification of viral load is investigational for organisms not on the medically necessary list. Gardnerella vaginalis and hepatitis G testing are investigational, outpatient respiratory viral panels may be considered medically necessary only when they involve 5 targets or less and the results will guide or alter management, and central nervous system, gastrointestinal and urogenital pathogen panels are investigational.
Special Alert December 2025 - Medicaid Benefit: Complex Rehab Technology (CRT) Repair at Providence Health Plan
Effective January 1, 2026, Providence Health Plan (Oregon Medicaid) eliminates prior authorization requirements for Complex Rehab Technology (CRT) repairs under Senate Bill 549. Providers must bill all CRT repair claims using modifier RB to ensure proper processing and avoid denials. Prior authorization is still required only for CRT replacements, new equipment/upgrades, or items that don't meet the SB 549 CRT definition.
Provider Chat Update: 24/7 Auth Status Check Is Now Live
Highmark has launched a new 24/7 automated authorization status check feature through Provider Chat in Availity. Providers can now check authorization status instantly at any time by accessing Provider Chat and selecting the 'Auth Status' option or typing relevant phrases.
Continued access to care through St. Charles Health System
PacificSource has secured network agreements with St. Charles Health System for Commercial plans (2026-2027) and Medicare plans (2026). No billing workflow changes are required—St. Charles providers remain in-network, and member coverage and access continue unchanged.
REVISED: 2025 Quarter 4 Healthcare Common Procedure Coding System Level II (HCPCS) Code and Current Procedural Terminology (CPT) Code Conversion
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Fall 2025 Authorization Updates
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Medicaid and Commercial Prior Authorization Changes
Effective January 1, 2026, both Commercial and Medicaid plans are implementing new prior authorization requirements for specific CPT/HCPCS codes. Additionally, certain HCPCS codes for Medicaid require prior authorization only when item costs exceed $500. The billing team must identify affected codes and implement authorization workflows before services are rendered.
Authorization Updates - Effective February 1, 2026
Sentara Health Plans relaxed prior authorization requirements for 499 codes for commercial products offered in Virginia, covering categories such as medical and surgical supplies, cardiovascular procedures, proprietary laboratory analyses and outpatient PPS codes. Effective February 1, 2026, commercial prior authorization is required for a further set of codes, several psychological testing codes now require authorization only after the listed hour limits, and several commercial codes, including 99070, A9286, G0330 and S9152, are not covered. Self-funded commercial products had separate prior authorization and not-covered code lists effective February 1, 2026, and Medicaid changes took effect October 1, 2025 and December 1, 2025.
Medical Association and Blue Cross and Blue Shield of Alabama Announce Patient Centered Enhancements to Prior Authorization Process
Blue Cross and Blue Shield of Alabama has implemented patient-centered enhancements to its prior authorization process, including elimination of AI-based denials, reduced repeat authorizations for chronic conditions, no reversal of approved services, expanded Gold Carding for trusted providers, online real-time approvals, 90-day prior auth portability between plans, and clearer transparency rules with 45-day notice for changes.
New Coverage for B4100 U1 – SIMPLY THICK FOOD THICKENER ORAL - CONCENTRATE/1 OZ
Effective November 1, 2025, Arkansas Department of Human Services added coverage for Simply Thick Food Thickener Oral – Concentrate/1 oz under procedure code B4100 U1. Billing teams must implement this new HCPCS code with 6 units per day at $2.20 per unit for home health, hospital, and therapy services.
Change to Prior Authorization Process for Physician-Administered Drugs – Effective January 1, 2026
Beginning January 1, 2026, Arkansas Medicaid is consolidating physician-administered drug (PAD) prior authorization requests to Prime Therapeutics, the existing pharmacy vendor. All PAD prior authorization requests must be submitted electronically through CoverMyMeds or by fax to Prime Therapeutics instead of previous processes. Billing teams must ensure staff are trained and CoverMyMeds registration is completed before the effective date.
Genetic Testing for Marfan Syndrome, Thoracic Aortic Aneurysms and Dissections, and Related Disorders (2.04.129)
Blue Shield of California covers individual genetic testing for Marfan syndrome, Ehlers-Danlos syndrome type IV, other thoracic aortic aneurysm and dissection syndromes, and related disorders when signs and symptoms of a connective tissue disorder are present but a definitive diagnosis cannot be made using established clinical diagnostic criteria. The genes covered for individual testing and focused panels are FBN1, MYH11, ACTA2, TGFBR1, TGFBR2 and COL3A1. Targeted familial variant testing in an asymptomatic individual may be considered medically necessary when a known pathogenic variant is present in the family, and genetic testing panels that are not limited to focused genetic testing are considered investigational.
Use of Common Genetic Variants (Single Nucleotide Variants) to Predict Risk of Nonfamilial Breast Cancer (2.04.63)
Blue Shield of California considers testing for one or more common single nucleotide variants (SNVs) to predict an individual's risk of breast cancer investigational. The GeneType breast cancer risk test is considered investigational for all indications, including use as a method of estimating individual risk for developing breast cancer. This version is effective September 1, 2026, and its policy statement has no changes from the previous version.
Carrier Screening for Genetic Diseases (2.04.107)
Blue Shield of California medical policy 2.04.107 treats targeted carrier screening for X-linked and autosomal recessive genetic diseases as medically necessary for individuals who are pregnant or considering pregnancy and are at increased risk of having offspring with one of these diseases. Targeted screening must meet one risk criterion (a first- or second-degree relative who is affected, a known carrier, or membership in a population with a carrier rate above the testing threshold) and all of six listed criteria. Those criteria include that alternative tests are not available or are less efficacious, that the genetic test has adequate clinical validity, and that previous carrier screening or individual targeted gene testing for the variant has not been performed. Non-targeted carrier screening panels may be considered medically necessary as an alternative to testing individual genes for individuals who are pregnant or considering pregnancy at any risk level, including high risk and average risk, when the listed criteria are met. Carrier screening is medically necessary only once per lifetime and should only be performed in adults. Targeted screening that does not meet the criteria, and non-targeted panels in all other situations, are considered investigational. The 11/01/2026 annual review made no change to the policy statement.
Genetic Testing for Heterozygous Familial Hypercholesterolemia (2.04.139)
Blue Shield of California covers genetic testing to confirm familial hypercholesterolemia (FH) only when a definitive diagnosis is required as an eligibility criterion for specialty medications, the individual is in an uncertain diagnostic category by clinical criteria, and alternative treatment considerations are in place for individuals with an uncertain diagnosis and a negative genetic test. Genetic testing to confirm FH in other situations, and genetic testing of adults who are close relatives of individuals with FH to determine future risk, are considered investigational. Genetic testing of children of individuals with FH to determine future risk may be considered medically necessary when a pathogenic variant is present in a parent and general lipid screening is not recommended based on age or other factors.
Genetic Testing for Hereditary Hearing Loss (2.04.87)
Genetic testing for hereditary hearing loss genes, including GJB2 and GJB6, may be considered medically necessary to confirm hereditary hearing loss in individuals with suspected hearing loss. Preconception carrier testing in parents may be considered medically necessary when at least one of four conditions is met: offspring with hereditary hearing loss, one or both parents with suspected hereditary hearing loss, a first- or second-degree relative affected with hereditary hearing loss, or a first-degree relative with an affected offspring. Testing in all other situations, including testing individuals without hearing loss, is considered investigational.
Baroreflex Stimulation Devices (8.01.57)
Blue Shield of California's medical policy 8.01.57 on baroreflex stimulation devices has an effective date of November 1, 2026, and its policy statement has not changed. Baroreflex stimulation therapy with an FDA-approved device is investigational for individuals with heart failure despite the use of maximally tolerated guideline-directed medical and device therapy, and for all other indications. The FDA-approved Barostim Neo system is indicated for patients with NYHA Class III or Class II heart failure (with a recent history of Class III) who remain symptomatic despite guideline-directed therapy, have an LVEF of 35% or less and NT-proBNP below 1600 pg/ml, and are not indicated for cardiac resynchronization therapy.
Noninvasive Techniques for the Evaluation and Monitoring of Patients With Chronic Liver Disease (2.04.41)
Blue Shield of California medical policy 2.04.41 covers noninvasive tests for evaluating and monitoring chronic liver disease. The FibroSURE multianalyte assay and transient elastography (FibroScan) may be considered medically necessary for evaluation of individuals with chronic liver disease, and both are considered investigational for monitoring. Other multianalyte assays with algorithmic analyses, and other noninvasive imaging including magnetic resonance elastography, multiparametric MRI, acoustic radiation force impulse imaging, and real-time tissue elastography, are considered investigational for evaluation or monitoring. The policy was updated on 01/01/2026 with a revised policy statement, guidelines and literature review.
Genetic Testing for FMR1 Variants (Including Fragile X Syndrome) (2.04.83)
Genetic testing for FMR1 variants may be considered medically necessary for individuals with characteristics of fragile X syndrome or a fragile X-associated disorder, including individuals with intellectual disability, developmental delay, or autism spectrum disorder, women with primary ovarian insufficiency under age 40 when fragile X-associated primary ovarian insufficiency is suspected, and individuals with neurologic symptoms consistent with fragile X-associated tremor or ataxia syndrome. It may also be considered medically necessary for individuals with a personal or family history of fragile X syndrome who are seeking reproductive counseling, including those with a family history of fragile X syndrome or undiagnosed intellectual disability, affected individuals or relatives with a positive cytogenetic fragile X test seeking carrier status information, and prenatal testing of fetuses of known carrier mothers. Genetic testing for FMR1 variants is investigational for all other uses.
Multibiomarker Disease Activity Blood Test for Rheumatoid Arthritis (2.04.119)
Blue Shield of California policy 2.04.119 considers the use of a multibiomarker disease activity score for rheumatoid arthritis, such as the Vectra score, investigational in all situations. The Vectra test measures 12 serum biomarkers and produces a disease activity score from 1 to 100, where 1-29 is low, 30-44 is moderate and 45-100 is high disease activity. The October 1, 2026 annual review updated the literature review without changing the policy statement, and the evidence is insufficient to determine that the technology improves net health outcomes.
Special Alert November 2025 - 2026 Outpatient Site of Service
Effective 1/1/2026, Providence Health Plan (Commercial Fully Insured only) now requires prior authorization for hernia repair and laparoscopic cholecystectomy procedures performed at hospital outpatient departments (place of service 22). Services must be performed at an ASC unless medical necessity criteria are met; the 3-hour surgery duration criterion has been removed as a valid reason for hospital outpatient use. Providers without accessible ASC privileges must file attestation to avoid claim denials.
2025 November Network Connection
Per Novitas, New Mexico's Medicare Administrative Contractor, physicians may bill evaluation and management (E/M) services furnished by a nonphysician practitioner 'incident to' their professional service, and the service must meet all the stated requirements and be medically necessary. 'Incident to' billing does not apply to a new patient or a new problem for an established patient, and all practitioners, whether supervising and billing or performing the services, must be actively employed by the same entity. Presbyterian prefers electronic claims submission, and when a previously submitted claim is denied, the existing claim is corrected and resubmitted with the right frequency code and/or indicator rather than creating a new claim.
Molecular Testing in the Management of Pulmonary Nodules (2.04.142)
Effective September 1, 2026, Blue Shield of California policy 2.04.142 considers plasma-based proteomic screening, including Nodify XL2 (BDX-XL2) and Nodify CDT, in individuals with undiagnosed pulmonary nodules detected by computed tomography to be investigational. The September 1, 2026 annual review updated the policy statement and literature review and included a coding update. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Genetic Testing for Duchenne and Becker Muscular Dystrophy (2.04.86)
Genetic testing for DMD gene variants may be considered medically necessary in males with signs and symptoms of a dystrophinopathy to confirm the diagnosis and direct treatment, in at-risk female relatives to confirm or exclude the need for cardiac surveillance or for preconception testing, and in at-risk male offspring to confirm or exclude the need for medical and cardiac surveillance. At-risk females are first- and second-degree female relatives, including the proband's mother, female siblings, female offspring, and the proband's maternal grandmother and maternal aunts, and at-risk males are asymptomatic male offspring of a female carrier or asymptomatic male siblings of an individual with a DMD-associated dystrophinopathy. Genetic testing for DMD gene variants is considered investigational in all other situations.
Chromosomal Microarray Testing for the Evaluation of Pregnancy Loss (2.04.122)
Chromosomal microarray (CMA) testing of fetal tissue may be considered medically necessary for evaluating pregnancy loss in individuals with indications for genetic analysis of the embryo or fetus. Genetic testing may be indicated, if desired by the parents, for pregnancy loss at 20 weeks of gestation or earlier when there is a maternal history of recurrent miscarriage (defined as 2 or more failed pregnancies), and in all cases of pregnancy loss after 20 weeks of gestation. The annual review effective November 1, 2026 made no changes to the policy statement.
Medica Provider News: November 2025
Effective October 1, 2025, Medica will not hold or deny claims related to telehealth services, and it continues to process Medicare telehealth claims as it did before the government shutdown. Effective November 1, 2025, Renflexis is added as a preferred biosimilar for infliximab through the medical benefit and does not require prior authorization, while non-preferred products require prior authorization. Effective January 1, 2026, preferred insulin products switch from Novo to Lilly products, and Effective February 1, 2026, Steqeyma and Yesintek become the preferred ustekinumab biosimilars that do not require prior authorization.
Gene Expression Profile Testing and Circulating Tumor DNA Testing for Predicting Recurrence in Colon Cancer (2.04.61)
Blue Shield of California considers gene expression profile (GEP) and circulating tumor DNA (ctDNA) assays for determining the prognosis of stage II or III colon cancer following surgery investigational. Medicare National and Local Coverage Determinations may also apply for members in health plans subject to the Biomarker Testing Law, and LCD selection depends on the location of the servicing laboratory. Oncotype DX Colon Cancer (81525) has a positive MolDx coverage determination for stage II patients considering adjuvant chemotherapy after definitive surgery, while GeneFx Colon and Colvera ctDNA tests are not registered in the MolDx DEX Diagnostics Exchange Registry.
Gene Expression Profiling for Cutaneous Melanoma (2.04.146)
Blue Shield of California's medical policy 2.04.146 considers gene expression testing for cutaneous melanoma investigational, including the Pigmented Lesion Assay for suspicious pigmented lesions, myPath Melanoma for melanocytic lesions with indeterminate histopathologic features, DecisionDx-Melanoma for all indications, and the Merlin test (CP-GEP). The policy statement adds the Merlin test to this list, and the policy's effective date is September 1, 2026. The policy states that the evidence is insufficient to determine that these technologies improve the net health outcome.
Genetic Testing for Statin-Induced Myopathy (2.04.96)
Blue Shield of California considers genetic testing for variants in the SLCO1B1 gene to identify individuals at risk of statin-induced myopathy investigational. This version is effective February 1, 2026, and the policy statement has no changes from the previous version. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
Germline Genetic Testing for Hereditary Breast/Ovarian Cancer Syndrome and Other High-Risk Cancers (BRCA1, BRCA2, PALB2) (2.04.02)
Blue Shield of California's policy 2.04.02 states that genetic testing for BRCA1, BRCA2 and PALB2 variants may be considered medically necessary in cancer-affected individuals who meet the listed personal or family history criteria, such as breast cancer diagnosed at age 45 years or younger, personal history of epithelial ovarian carcinoma, or personal history of exocrine pancreatic cancer. BRCA1 and BRCA2 testing outside those criteria, PALB2 testing for individuals who do not meet the criteria, and testing in minors are considered investigational. This version is effective November 1, 2026, and the policy statement has no changes from the previous version.
Behavioral Health Treatment for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)
Blue Shield of California medical policy BSC3.01 covers outpatient behavioral health treatment, including applied behavior analysis (ABA), for autism spectrum disorder or pervasive developmental disorder when it is medically necessary. Blue Shield covers BHT/ABA when it is state mandated or when it is specifically included in a member's benefit plan. Respite, day care, educational services, and reimbursing a parent for participating in treatment are generally not covered benefits.
Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Non-Small-Cell Lung Cancer (EGFR, ALK, BRAF, ROS1, RET, MET, KRAS, NTRK) (2.04.45)
Blue Shield of California Medical Policy 2.04.45 sets criteria for somatic biomarker testing in advanced or metastatic non-small-cell lung cancer (NSCLC) for EGFR, ALK, BRAF, ROS1, RET, MET, KRAS and NTRK variants, to select targeted therapy. Tissue testing may be considered medically necessary when the individual has no FDA-labeled contraindication to the requested agent and the agent is used consistently with its FDA-approved label, and plasma testing may be considered as an alternative to tissue biopsy for EGFR, ALK, KRAS, MET exon 14 skipping and NTRK when an FDA-approved companion diagnostic plasma test is used, while plasma testing for BRAF V600E, ROS1 and RET is considered investigational. The February 1, 2026 update was administrative, and the policy statement has no changes from the previous version.
Liposuction for Lipedema and Lymphedema (7.01.169)
Blue Shield of California policy 7.01.169 considers lipectomy or liposuction medically necessary for lipedema or lymphedema only when all listed criteria for that condition are met. These include a documented diagnosis, at least three consecutive months of conservative management that did not respond, documented functional impairment or medical complications for each anatomical region being treated, and surgery by a hospital credentialed, board-certified plastic surgeon experienced in treating that condition. The 10/01/2026 annual review updated the policy guidelines, the policy statement and the literature review, and included a coding update. The region-by-region wording now reads that one of the following criteria is met, where the previous version said either of the following criteria are met. Liposuction for lipedema or lymphedema in all other situations is considered investigational.
Authorization Updates - Effective January 1, 2026
Sentara Health Plans' October 2025 medical policy update takes effect January 1, 2026. From that date, prior authorization is required for several commercial orthotic codes and J3590, and precertification or prior authorization is required for J7198 and for denosumab codes J0897 and Q5136, which also apply to Medicare and commercial products; Medicaid adds Q5157, Q5158 and Q5159. Several commercial codes, including 90880 and S8940, will no longer be covered, and many commercial orthotic codes no longer require prior authorization.
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