All Insurance Policy Changes (Page 16)

Continuing from page 15. Showing older policy changes tracked across all payers. Use the filters in the related-hubs section below to narrow by provider, state, or specialty.

High impact
Maximum Dosage and Frequency (for Ohio Only)
UnitedHealthcare·Effective Oct 1, 2026
This policy cannot be fully analyzed because the actual policy content text is not provided. The source document is referenced but the specific maximum dosage and frequency requirements, affected drugs, or billing changes are not included in the submission. The billing team cannot implement changes without the detailed policy language.
Medium impact
Adzynma (ADAMTS13, Recombinant-Krhn) (for Ohio Only)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of Ohio has updated its medical benefit drug policy for Adzynma (ADAMTS13, Recombinant-Krhn), effective October 1, 2026. This is a new policy specific to Ohio Medicaid members. The billing team must review the complete policy document to understand coverage criteria, prior authorization requirements, and any applicable billing codes for this rare disease therapeutic.
Medium impact
Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for North Carolina Only)
UnitedHealthcare·Effective Sep 1, 2026
UnitedHealthcare Community Plan of North Carolina has RETIRED its medical policy on embolization of the ovarian and iliac veins for pelvic congestion syndrome, effective September 1, 2026. This policy retirement removes prior coverage guidance for this procedure in North Carolina Medicaid. Billing teams must determine whether claims for this procedure will now follow standard coverage rules or be denied.
Medium impact
Zolgensma® (Onasemnogene Abeparvovec-Xioi)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of New Mexico has issued a revised medical benefit drug policy for Zolgensma® (Onasemnogene Abeparvovec-Xioi) effective October 1, 2026. The policy details coverage requirements, limitations, and medical necessity criteria for this gene therapy treatment. Billing teams must review the full policy document to identify any changes to prior authorization requirements, covered indications, or billing procedures compared to previous guidance.
Medium impact
Tzield® (Teplizumab-Mzwv)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of New Jersey has issued a revised medical policy for Tzield® (Teplizumab-Mzwv), a newly approved immunotherapy drug. The policy details coverage criteria, prior authorization requirements, and billing guidelines for this Medicaid benefit effective October 1, 2026. Billing teams must implement new prior authorization workflows and update systems to reflect this new drug coverage.
Medium impact
Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for New Jersey Only)
UnitedHealthcare·Effective Sep 1, 2026
Unable to analyze this policy change. The provided policy information contains only metadata (title, bulletin details, effective date, and source URL) without the actual policy content. The full policy text required to identify specific billing codes, coverage criteria, prior authorization requirements, and clinical guidelines is not included in the submission.
Medium impact
Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Nebraska Only)
UnitedHealthcare·Effective Sep 1, 2026
UnitedHealthcare Community Plan of Nebraska's Medicaid program now mandatorily covers routine patient costs (such as travel, lodging, and care coordination) for qualifying clinical trial participants, effective September 1, 2026. This expands coverage to support patient participation in approved clinical trials and requires billing teams to recognize and process these routine costs as covered benefits rather than patient financial responsibility.
Medium impact
Otarmeni™ (Lunsotogene Parvec-Cwha)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of Kentucky has issued a new medical benefit drug policy for Otarmeni™ (Lunsotogene Parvec-Cwha) effective October 1, 2026. The policy document has been published but specific coverage criteria, billing codes, prior authorization requirements, and reimbursement details are not provided in the source material available.
Medium impact
FDA Cleared or Approved Companion Diagnostic Testing (for Idaho Only)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of Idaho (Medicaid) has updated its medical policy on FDA Cleared or Approved Companion Diagnostic Testing effective October 1, 2026. This policy establishes coverage guidelines for companion diagnostic tests used to identify patient populations most likely to benefit from specific therapeutics. Billing teams must review the complete policy details to understand which tests require prior authorization, documentation requirements, and any limitations on coverage.
Medium impact
Cell-Free Fetal DNA Testing (for Idaho Only)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan of Idaho has issued a medical policy update effective October 1, 2026 regarding Cell-Free Fetal DNA Testing coverage for Idaho Medicaid members. The billing team must review the full policy document to understand coverage criteria, authorization requirements, and applicable billing codes for this prenatal screening service.
High impact
Autologous Cellular Therapy (for Idaho Only)
UnitedHealthcare·Effective Oct 1, 2026
INCOMPLETE POLICY DATA: The provided policy change notice contains metadata headers but no actual policy content, coverage criteria, billing code changes, or clinical guidance. The billing team cannot implement this change without the full policy document detailing what autologous cellular therapy procedures are covered, any prior authorization requirements, applicable billing codes, or reimbursement rules for Idaho Medicaid.
Medium impact
Tzield® (Teplizumab-Mzwv)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan (Medicaid) has issued a revised medical benefit drug policy for Tzield® (Teplizumab-Mzwv) effective October 1, 2026. The policy document title and category indicate this is a coverage and/or billing guidance update for this pharmaceutical product, but the specific policy details are not provided in the source material shared.
Medium impact
Itvisma® (Onasemnogene Abeparvovec-Brve)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Community Plan (Medicaid) has issued a revised medical policy for Itvisma® (Onasemnogene Abeparvovec-Brve), a gene therapy treatment. The policy becomes effective October 1, 2026. The billing team must review the full policy document to identify coverage criteria, prior authorization requirements, and applicable billing codes for this newly revised benefit.
Medium impact
Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver
UnitedHealthcare·Effective Nov 1, 2026
UnitedHealthcare has revised its medical policy on Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for malignant liver cancers effective November 1, 2026. This is a revised policy affecting Exchange plans nationally. The billing team must review the specific coverage criteria, prior authorization requirements, and any billing code changes outlined in the full policy document to ensure compliant claims processing.
Medium impact
Tzield® (Teplizumab-Mzwv)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare has issued a revised medical benefit drug policy for Tzield® (Teplizumab-Mzwv) effective October 1, 2026. The policy document was published in the September 2026 UMR Medical Policy Update Bulletin. However, the specific policy content details are not provided in the source material, preventing analysis of what coverage, prior authorization, or billing requirements have changed.
Medium impact
Tzield® (Teplizumab-Mzwv)
UnitedHealthcare·Effective Oct 1, 2026
UnitedHealthcare Surest has issued a revised medical benefit drug policy for Tzield® (Teplizumab-Mzwv) effective October 1, 2026. The policy document title and metadata are provided, but the actual policy content details (coverage criteria, prior authorization requirements, billing codes, dosing, and medical necessity guidelines) are not included in the source material available for analysis.
Medium impact
Zusduri (mitomycin) (Revised)
Humana·Effective Aug 27, 2025
This is a new Humana prior authorization policy for Zusduri (mitomycin) intravesical treatment for recurrent low-grade intermediate-risk non-muscle invasive bladder cancer (LG-IR-NMIBC), effective August 27, 2025. Coverage requires documented recurrent disease, no prior Zusduri therapy, and absence of bladder perforation. Initial and renewal approval is limited to 6 months (maximum 6 doses per period).
Medium impact
Zelsuvmi™ (berdazimer) (Revised)
Humana·Effective Aug 27, 2025
Humana Medicare Advantage has established a new prior authorization policy for Zelsuvmi (berdazimer) topical gel for molluscum contagiosum treatment. Coverage requires documentation that the patient has a confirmed molluscum contagiosum diagnosis AND has failed, been contraindicated, or intolerant to conventional therapies (podofilox, cimetidine, or imiquimod). All Zelsuvmi prescriptions now require prior authorization before dispensing.
Medium impact
Thrombate III® [Antithrombin III (Human)] (Revised)
Humana·Effective Aug 27, 2025
Humana Indiana Medicaid has issued a revised prior authorization policy for Thrombate III (Antithrombin III Human), effective August 27, 2025. Coverage requires documented hereditary antithrombin deficiency and use for treatment or prevention of thromboembolism, including peri-operative or peri-partum prophylaxis. This is a new policy establishment for this specific drug with defined authorization criteria.
Medium impact
Zusduri (mitomycin) (Revised)
Humana·Effective Oct 1, 2025
This is a new Humana Medicaid (Indiana) prior authorization policy for Zusduri (mitomycin) intravesical instillation for recurrent low-grade intermediate-risk non-muscle invasive bladder cancer. Coverage requires prior auth, patient must have documented recurrent disease, have not received prior Zusduri therapy (max 6 doses), and must not have bladder perforation. Initial and renewal approvals cover 6 months (maximum 6 doses per period).
Medium impact
Zusduri (mitomycin) (Revised)
Humana·Effective Oct 1, 2025
Humana Louisiana Medicaid has issued a revised prior authorization policy for Zusduri (mitomycin) intravesical treatment for recurrent low-grade intermediate-risk non-muscle invasive bladder cancer (LG-IR-NMIBC). This is a fresh policy dated August 26, 2026, requiring prior authorization before dispensing. Billing teams must verify patient meets all three coverage criteria (LG-IR-NMIBC diagnosis, documented recurrent disease, no prior Zusduri therapy) and has no bladder perforation exclusion.
Medium impact
Zoladex (goserelin) (Revised)
Humana·Effective Oct 1, 2025
This is a revised Humana Medicaid (Indiana) prior authorization policy for Zoladex (goserelin) effective October 1, 2025. The policy establishes specific approval criteria for four indications: prostate cancer (advanced or high recurrence risk), breast cancer (pre/perimenopausal, hormone receptor positive), endometriosis (3.6 mg only), and endometrial thinning (3.6 mg only, 2-month approval). Key exclusions include concomitant LHRH agent use, pediatric patients under 18, disease progression in breast cancer, and abnormal vaginal bleeding of unknown etiology. Prior authorization is required for all uses.
Medium impact
Zoladex (goserelin) (Revised)
Humana·Effective Oct 1, 2025
This is a revised Humana Medicaid (Louisiana) prior authorization policy for Zoladex (goserelin) effective October 1, 2025. The policy establishes specific clinical criteria and exclusions for four approved indications: prostate cancer, breast cancer, endometriosis, and endometrial thinning. Billing teams must verify prior authorization requirements before claim submission and ensure member eligibility against specific criteria including age restrictions, concomitant medication exclusions, and dosage-form requirements.
Medium impact
Tivdak (tisotumab vedotin-tftv) (New)
Humana·Effective Oct 1, 2025
Humana Indiana Medicaid has implemented a new prior authorization policy for Tivdak (tisotumab vedotin-tftv), a cancer treatment for recurrent or metastatic cervical cancer. Coverage requires disease progression after chemotherapy, a CPS score ≥1, medical contraindication to pembrolizumab, and monotherapy administration. Prior authorization is mandatory before dispensing.
Medium impact
Tivdak (tisotumab vedotin-tftv) (New)
Humana·Effective Oct 1, 2025
Humana Medicaid (Ohio) has issued a new prior authorization policy for Tivdak (tisotumab vedotin-tftv), a cancer treatment for recurrent/metastatic cervical cancer. The policy requires prior auth for this intravenous monotherapy when used as subsequent treatment after chemotherapy failure, with specific clinical criteria including CPS score assessment and documented medical reason for not using Keytruda. Billing teams must implement prior authorization requirements before claims submission.

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2023 2024 2025 2026

Insurance Policy Changes Tracker: All Payer Updates (Page 16) | PolicyChanges.app

Maximum Dosage and Frequency (for Ohio Only)

Adzynma (ADAMTS13, Recombinant-Krhn) (for Ohio Only)

Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome (for North Carolina Only)

Zolgensma® (Onasemnogene Abeparvovec-Xioi)

Tzield® (Teplizumab-Mzwv)

Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes (for New Jersey Only)

Mandatory Medicaid Coverage of Routine Patient Costs in Qualifying Clinical Trials (for Nebraska Only)

Otarmeni™ (Lunsotogene Parvec-Cwha)

FDA Cleared or Approved Companion Diagnostic Testing (for Idaho Only)

Cell-Free Fetal DNA Testing (for Idaho Only)

Autologous Cellular Therapy (for Idaho Only)

Tzield® (Teplizumab-Mzwv)

Itvisma® (Onasemnogene Abeparvovec-Brve)

Transarterial Radioembolization (TARE)/Selective Internal Radiation Therapy (SIRT) for the Treatment of Malignant Cancers of the Liver

Tzield® (Teplizumab-Mzwv)

Tzield® (Teplizumab-Mzwv)

Zusduri (mitomycin) (Revised)

Zelsuvmi™ (berdazimer) (Revised)

Thrombate III® [Antithrombin III (Human)] (Revised)

Zusduri (mitomycin) (Revised)

Zusduri (mitomycin) (Revised)

Zoladex (goserelin) (Revised)

Zoladex (goserelin) (Revised)

Tivdak (tisotumab vedotin-tftv) (New)

Tivdak (tisotumab vedotin-tftv) (New)