All Insurance Policy Changes (Page 1251)

Continuing from page 1250. 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
Retifanlimab-dlwr (Zynyz™)
BCBS Tennessee·Effective Jul 31, 2026
New medical policy establishing coverage criteria for Retifanlimab-dlwr (Zynyz™), a cancer immunotherapy drug requiring prior authorization for multiple cancer types including anal canal carcinoma, Merkel cell carcinoma, and several gastrointestinal cancers. Policy requires specific laboratory documentation and excludes patients who progressed on prior PD-1/PD-L1 inhibitor therapy.
Low impact
Plasminogen, human-tvmh (Ryplazim®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Ryplazim® (plasminogen, human-tvmh) for treatment of plasminogen deficiency type 1. The policy requires prior authorization with specific coverage criteria including baseline plasminogen activity levels ≤45% and documented history of lesions, and must be prescribed by or in consultation with a hematologist.
Medium impact
Pasireotide (Signifor® LAR)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has established a new medical policy for Pasireotide (Signifor LAR) requiring step therapy and prior authorization for treatment of acromegaly and Cushing's disease. The policy requires specific laboratory documentation including IGF-1 levels for acromegaly and cortisol levels for Cushing's disease, with 12-month authorization periods.
Medium impact
Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new policy for octreotide suspension (Sandostatin LAR Depot) that establishes prior authorization requirements and specific coverage criteria for multiple conditions including acromegaly, neuroendocrine tumors, and various gastrointestinal disorders. The policy requires specific documentation and laboratory results for approval and continuation of therapy.
Medium impact
Noninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases
BCBS Tennessee·Effective Jul 31, 2026
New policy establishes coverage criteria for noninvasive liver imaging techniques. FibroScan (transient elastography) is medically necessary for chronic liver disease evaluation. MRE (magnetic resonance elastography) is medically necessary only for specific chronic liver disease cases when strict criteria are met. All other noninvasive liver imaging techniques are considered investigational.
Low impact
Nedosiran (Rivfloza™)
BCBS Tennessee·Effective Jul 31, 2026
New coverage policy for Nedosiran (Rivfloza™) for primary hyperoxaluria type 1 treatment, requiring prior authorization with genetic testing confirmation and specialist prescription. Policy requires 12-month authorization cycles with specific coverage criteria including age 2+, preserved kidney function, and cannot be combined with Oxlumo.
Low impact
Lumasiran (Oxlumo®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Lumasiran (Oxlumo®) for primary hyperoxaluria type 1 treatment, requiring prior authorization with genetic testing confirmation and specialist prescribing. The policy establishes comprehensive coverage criteria including molecular testing requirements and excludes combination with certain other medications.
Medium impact
Lanreotide (Somatuline® Depot; Lanreotide)
BCBS Tennessee·Effective Jul 31, 2026
BCBS Tennessee is implementing a new medical policy for Lanreotide (Somatuline Depot) with step therapy requirements and specific prior authorization criteria for acromegaly and neuroendocrine tumors. The policy requires documentation of high IGF-1 levels for acromegaly and allows 12-month authorizations for various covered indications.
Medium impact
Isatuximab-irfc (Sarclisa®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Isatuximab-irfc (Sarclisa®) for multiple myeloma and related conditions, establishing coverage criteria and prior authorization requirements for 12-month approvals. The policy covers FDA-approved indications and specific compendial uses but requires meeting detailed approval criteria.
Medium impact
Inclisiran (Leqvio®)
BCBS Tennessee·Effective Jul 31, 2026
New medical policy establishes prior authorization requirements for Inclisiran (Leqvio®) for cholesterol management, requiring specialist prescribing and specific documentation of LDL-C levels, ASCVD history, and statin therapy trials. The policy includes detailed coverage criteria based on cardiovascular risk and current cholesterol levels.
Low impact
Evinacumab-dgnb (Evkeeza™)
BCBS Tennessee·Effective Jul 31, 2026
New policy establishes coverage criteria for Evinacumab-dgnb (Evkeeza™) for treating homozygous familial hypercholesterolemia in patients 1+ years old. Policy requires prior authorization with genetic testing confirmation and specific specialist prescribing requirements.
Medium impact
Elotuzumab (Empliciti®
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has established a new medical policy for Elotuzumab (Empliciti®) that will require prior authorization for multiple myeloma and related conditions. The policy covers FDA-approved indications and specific compendial uses, with 12-month authorization periods when used in approved combination therapies.
Low impact
Elivaldogene Autotemcel (Skysona®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Elivaldogene Autotemcel (Skysona®), a gene therapy for boys aged 4-17 with early, active cerebral adrenoleukodystrophy (CALD). The policy establishes extensive prior authorization requirements and coverage criteria for this specialized treatment.
Medium impact
Denosumab Products: (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-desu (Osvyrti); Denosumab-bmwo (Stoboclo®)
BCBS Tennessee·Effective Jul 31, 2026
New comprehensive policy for denosumab products (Prolia and 9 biosimilars) establishes specific coverage criteria, prior authorization requirements, and documentation standards for osteoporosis, cancer-related bone loss, and rheumatoid arthritis treatments. The policy includes detailed approval criteria for different patient populations and sets 12-month authorization periods with specific continuation requirements.
Medium impact
Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)
BCBS Tennessee·Effective Jul 31, 2026
New medical policy for Darzalex Faspro (daratumumab and hyaluronidase-fihj) establishing prior authorization requirements for multiple myeloma, light chain amyloidosis, POEMS syndrome, and related conditions. Policy covers FDA-approved indications and compendial uses with specific combination therapy requirements and documentation needs.
Medium impact
Daratumumab (Darzalex®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has released a new comprehensive medical policy for Daratumumab (Darzalex®) covering multiple myeloma and other conditions, establishing detailed coverage criteria and prior authorization requirements. This policy will not take effect until July 31, 2026, giving practices nearly two years to prepare.
Medium impact
Circulating Tumor DNA (Liquid Biopsy)
BCBS Tennessee·Effective Jul 31, 2026
New medical policy establishes coverage criteria for circulating tumor DNA (liquid biopsy) testing. FDA-approved companion diagnostic assays like FoundationOne Liquid CDx and Guardant360 CDx are considered medically necessary for advanced/metastatic solid tumors when specific criteria are met, while Signatera testing remains investigational.
Medium impact
Cemiplimab-rwlc (Libtayo®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has established a new comprehensive medical policy for Cemiplimab-rwlc (Libtayo®), a cancer immunotherapy drug. The policy covers FDA-approved indications and compendial uses for various cancers including skin cancers, lung cancer, and several other malignancies, with specific prior authorization requirements and coverage criteria for each indication.
High impact
Carfilzomib (Kyprolis®)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee has established a new medical policy for Carfilzomib (Kyprolis®) requiring prior authorization for multiple myeloma and other specified conditions. The policy includes detailed coverage criteria, dosing limits, and requires specific documentation including translocation t(11:14) where applicable.
Medium impact
Bortezomib (Velcade®; Bortezomib, Boruzu™)
BCBS Tennessee·Effective Jul 31, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for bortezomib (Velcade, Boruzu) covering multiple cancer conditions and other specified indications. The policy establishes coverage criteria, dosing limits, and 12-month authorization periods for various oncologic and hematologic conditions.
High impact
Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)
BCBS Tennessee·Effective Jul 31, 2026
Fresh policy update covering bevacizumab products (Avastin and biosimilars) for cancer treatment and ophthalmic disorders. This comprehensive policy establishes coverage criteria with 6-month authorizations for eye conditions and 12-month authorizations for various cancers, with step therapy requirements for some specialty medications.
Medium impact
Secukinumab (Cosentyx®)
BCBS Tennessee·Effective Sep 1, 2026
New prior authorization policy for Cosentyx (secukinumab) will require step therapy and specialist prescribing for multiple conditions including psoriasis, psoriatic arthritis, and ankylosing spondylitis. Policy includes detailed coverage criteria and documentation requirements for each indication.
Medium impact
Inclisiran (Leqvio®)
BCBS Tennessee·Effective Sep 1, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Inclisiran (Leqvio®) coverage that requires prior authorization with specific criteria for hypercholesterolemia and familial hypercholesterolemia treatment. The policy includes strict LDL-C level requirements, mandatory statin therapy trials, and specialist prescriber requirements.
High impact
AHCCCS DFSM Claims Clues - IHS/638 Claim Audit Memo
Arizona Medicaid - AHCCCS·Effective Dec 23, 2014
AHCCCS Division of Fee for Service Management has identified common billing errors during recent audits of IHS/638 facilities, including improper pharmacy claims, vaccine billing, and unbundling issues. Billers must review current policies to ensure compliance and avoid audit findings.
Medium impact
AHCCCS DFSM Claims Clues - FFS Billing Specialty NF & HCBS Rate Increase Effective 1-1-17
Arizona Medicaid - AHCCCS·Effective Jan 1, 2017
AHCCCS increased specialty rates effective January 1, 2017 - 3.5% for nursing facilities and 7% for assisted living facilities providing specific HCBS services (T2031, T2033). Claims paid at old rates must be replaced with new claims at increased rates.

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Archive by year

2023 2024 2025 2026

Retifanlimab-dlwr (Zynyz™)

Plasminogen, human-tvmh (Ryplazim®)

Pasireotide (Signifor® LAR)

Octreotide Suspension (Sandostatin® LAR Depot), Octreotide Acetate for Injectable Suspension

Noninvasive Imaging Techniques for Evaluation and Monitoring of Chronic Liver Diseases

Nedosiran (Rivfloza™)

Lumasiran (Oxlumo®)

Lanreotide (Somatuline® Depot; Lanreotide)

Isatuximab-irfc (Sarclisa®)

Inclisiran (Leqvio®)

Evinacumab-dgnb (Evkeeza™)

Elotuzumab (Empliciti®

Elivaldogene Autotemcel (Skysona®)

Denosumab Products: (Prolia®); Denosumab-nxxp (Bildyos®); Denosumab-mobz (Boncresa);Denosumab-kyqq (Bosaya™); Denosumab-bnht (Conexxence®); Denosumab-qbde (Enoby™); Denosumab-bbdz (Jubbonti®); Denosumab-dssb (Ospomyv™); Denosumab-desu (Osvyrti); Denosumab-bmwo (Stoboclo®)

Daratumumab and hyaluronidase-fihj (Darzalex Faspro®)

Daratumumab (Darzalex®)

Circulating Tumor DNA (Liquid Biopsy)

Cemiplimab-rwlc (Libtayo®)

Carfilzomib (Kyprolis®)

Bortezomib (Velcade®; Bortezomib, Boruzu™)

Bevacizumab Products (Avastin®; Mvasi® ; Zirabev™; Alymsys®; Vegzelma™, Avzivi®, Jobevne™)

Secukinumab (Cosentyx®)

Inclisiran (Leqvio®)

AHCCCS DFSM Claims Clues - IHS/638 Claim Audit Memo

AHCCCS DFSM Claims Clues - FFS Billing Specialty NF & HCBS Rate Increase Effective 1-1-17