All Insurance Policy Changes (Page 124)

Continuing from page 123. 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
MAB2026070102
Pennsylvania Medicaid (DHS)·Effective Jul 6, 2026
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for Intra-Articular Hyaluronates effective July 6, 2026. The key change clarifies that renewal prior authorizations must document improvement following the MOST RECENT treatment (not the first treatment). All intra-articular hyaluronate prescriptions now require prior authorization, with specific clinical criteria including failure of non-pharmacologic treatments, acetaminophen/NSAIDs, and intra-articular glucocorticoids.
High impact
MAB2026070103
Pennsylvania Medicaid (DHS)·Effective Jul 6, 2026
Pennsylvania Medical Assistance updated prior authorization requirements for Lipotropics, Other medications effective July 6, 2026. Changes include new FDA-approved drug Redemplo (plozasiran), revised cholesterol goal metrics (non-HDL-C and apoB), updated statin trial guidelines, modified icosapent ethyl requirements, and new renewal guidelines for non-preferred PCSK9 inhibitors. Pharmacy and prescriber practices must follow updated clinical review guidelines when submitting prior authorization requests.
High impact
MAB2026070104
Pennsylvania Medicaid (DHS)·Effective Jul 6, 2026
Pennsylvania Medical Assistance updated prior authorization guidelines for drugs exceeding quantity limits/daily dose limits, effective July 6, 2026. The policy revises clinical review criteria to include new guidelines for partial-unit dosing, multiple-unit consolidation, titration packs, medical reasons for frequent dosing, and documentation of failed lower-dose trials. Prescribers and pharmacies must now provide enhanced documentation to support medical necessity requests.
High impact
MAB2026070105
Pennsylvania Medicaid (DHS)·Effective Jul 1, 2026
Pennsylvania Medical Assistance (MA) program is implementing new prior authorization guidelines effective July 1, 2026 for wheelchair cushions and accessories exceeding three months of use. All prescriptions for purchase or rental must now include comprehensive clinical documentation (diagnoses, therapy evaluations, physical function assessments, wheelchair details, body measurements, and for accessories, documentation of failed alternatives) to demonstrate medical necessity. This applies to Fee-for-Service MA beneficiaries only; managed care organizations have separate processes.
Medium impact
MA08.042l, Ustekinumab for Intravenous Use
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
High impact
MA08.052q, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Effective Jul 1, 2026
This is a NEW Medicare Advantage policy (MA08.052q) effective July 1, 2026, governing coverage and billing for Denosumab (Prolia® and Xgeva®), related biosimilars, and Romosozumab-aqqg (Evenity®). The policy establishes updated rules for these bone health medications. However, the full policy text content was not provided in this notification, so specific coverage criteria, prior authorization requirements, or billing rule changes cannot be detailed.
High impact
MA08.073v, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin-2 (Ang-2) Inhibitors
Independence Blue Cross·Effective Jul 1, 2026
Medicare Advantage policy MA08.073v establishes updated coverage and clinical guidelines for intravitreal injections of VEGF antagonists, VEGF biosimilars, and combination VEGF/Ang-2 inhibitors effective July 1, 2026. The billing team must review the full policy text to identify specific prior authorization requirements, covered medications, dosing limits, and any billing code changes that may affect claim submission and reimbursement for these retinal therapies.
Medium impact
MA08.150b, Intravenous (IV) Iron Preparations
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
MA08.192a, Belantamab mafodotin-blmf (Blenrep)
Independence Blue Cross·Effective Jul 1, 2026
This is a Medicare Advantage policy update for Belantamab mafodotin-blmf (Blenrep), a monoclonal antibody used in oncology. The policy became effective on July 1, 2026. Without access to the full policy text, specific coverage criteria, prior authorization requirements, or billing code changes cannot be determined from the provided information.
Medium impact
MA08.024o, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Exdensur, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
High impact
MA08.009z, Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
Independence Blue Cross·Effective Jul 1, 2026
Unable to provide complete analysis. The policy document content was not included in the source material provided. While the policy metadata indicates MA08.009z covers Immune Globulin Intravenous (IVIG) and Subcutaneous (SCIG) for Medicare Advantage plans effective 07/01/2026, the actual policy details (coverage rules, billing codes, prior auth requirements, documentation changes) are not available. The billing team must access the full policy text from the provided URL to determine specific billing and operational impacts.
Medium impact
MA08.082q, Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars
Independence Blue Cross·Effective Jul 1, 2026
This is a new Medicare Advantage policy effective July 1, 2026, establishing coverage and billing guidelines for granulocyte-colony stimulating factor (G-CSF) products including Ryzneuta® (efbemalenograstim alfa-vuxw), Rolvedon™ (eflapegrastim-xnst), Neulasta® (pegfilgrastim), and related biosimilars. The policy provides updated coverage criteria and billing requirements for these chemotherapy support medications.
Medium impact
MA08.148d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
MA05.060g, External Infusion Pumps
Independence Blue Cross·Effective Jul 1, 2026
Unable to provide detailed analysis. The policy document MA05.060g (External Infusion Pumps) for Medicare Advantage was posted on 07/01/2026 with an effective date of 07/01/2026, but the actual policy content was not provided in the source material. A direct review of the full policy text at the provided URL is required to identify specific billing code changes, coverage modifications, and billing team action items.
Medium impact
MA08.026n, Treatments for Complex Regional Pain Syndrome (CRPS)
Independence Blue Cross·Effective Jul 1, 2026
Unable to complete analysis. The policy content for MA08.026n (Treatments for Complex Regional Pain Syndrome) was not provided in the source material. While the policy metadata indicates it is a Medicare Advantage medical policy effective 07/01/2026, the actual policy text detailing coverage criteria, billing codes, prior authorization requirements, or other specific changes is needed to provide actionable guidance to the billing team.
Medium impact
MA06.034u, eviCore Lab Management
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
MA05.010l, Ankle-Foot/Knee-Ankle-Foot Orthosis
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
High impact
MA00.003ah, Preventive Care Services
Independence Blue Cross·Effective Jul 1, 2026
Medicare Advantage policy MA00.003ah for Preventive Care Services has been updated with changes to Medical Necessity Criteria and Medical Coding effective July 1, 2026. The billing team must review the full policy document to identify specific code changes and documentation requirements, as the provided source does not contain detailed clinical criteria or affected billing codes.
Medium impact
MA09.002ah, High-Technology Radiology Services
Independence Blue Cross·Effective May 17, 2026
Policy MA09.002ah establishes new medical coding guidelines for high-technology radiology services under Medicare Advantage plans, effective May 17, 2026. The billing team must review and implement coding requirement changes for advanced radiology procedures to ensure compliant claim submission starting on the effective date.
Medium impact
MA00.026ab, Bundled Procedure Codes
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
High impact
MA03.005d, Modifiers XE, XP, XS, XU, and 59
Independence Blue Cross·Effective Oct 1, 2026
Medicare Advantage policy MA03.005d updates guidance on the use of modifier XE, XP, XS, XU, and legacy modifier 59 for distinguishing separately identifiable services. This is a coverage and reimbursement position change affecting how these modifiers are applied to claims submitted to MA plans. Billing teams must understand the updated modifier requirements and application rules effective October 1, 2026.
Medium impact
07/01/2026 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
08.00.82q, Ustekinumab for Intravenous Infusion
Independence Blue Cross·Effective Jul 1, 2026
Policy 08.00.82q for Ustekinumab intravenous infusion has been updated effective July 1, 2026. This is a commercial pharmacy policy update that may affect coverage criteria, prior authorization requirements, or reimbursement for IV ustekinumab administration. The billing team must review the full policy details to identify specific changes to claims processing.
Medium impact
08.00.94w, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change
Medium impact
08.00.74ac, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin-2 (Ang-2) Inhibitors
Independence Blue Cross·Identified Jul 2, 2026
Failed to analyze policy change

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MAB2026070102

MAB2026070103

MAB2026070104

MAB2026070105

MA08.042l, Ustekinumab for Intravenous Use

MA08.052q, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)

MA08.073v, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin-2 (Ang-2) Inhibitors

MA08.150b, Intravenous (IV) Iron Preparations

MA08.192a, Belantamab mafodotin-blmf (Blenrep)

MA08.024o, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Exdensur, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)

MA08.009z, Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)

MA08.082q, Efbemalenograstim alfa-vuxw (Ryzneuta®), Eflapegrastim-xnst (Rolvedon™), Pegfilgrastim (Neulasta®) and Related Biosimilars

MA08.148d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)

MA05.060g, External Infusion Pumps

MA08.026n, Treatments for Complex Regional Pain Syndrome (CRPS)

MA06.034u, eviCore Lab Management

MA05.010l, Ankle-Foot/Knee-Ankle-Foot Orthosis

MA00.003ah, Preventive Care Services

MA09.002ah, High-Technology Radiology Services

MA00.026ab, Bundled Procedure Codes

MA03.005d, Modifiers XE, XP, XS, XU, and 59

07/01/2026 CPT & HCPCS Quarterly Code Update Coverage Determinations for Medicare Advantage Products

08.00.82q, Ustekinumab for Intravenous Infusion

08.00.94w, Denosumab (Prolia®, Xgeva®) and related biosimilars, and Romosozumab-aqqg (Evenity®)

08.00.74ac, Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists, VEGF Biosimilars, and Combination VEGF/Angiopoietin-2 (Ang-2) Inhibitors