All Insurance Policy Changes (Page 17)

Continuing from page 16. 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
Zurzuvae® (zuranolone) (Revised)
Humana·Effective Jan 1, 2026
Humana Medicare Advantage has established a revised prior authorization policy for Zurzuvae® (zuranolone) for postpartum depression treatment, effective January 1, 2026. The policy requires prior authorization and defines strict eligibility criteria including diagnosis timing, treatment window (within 1 year postpartum), and a single 14-day course limitation per episode. Billing teams must implement prior authorization workflows and ensure claims compliance with these new requirements.
Medium impact
Trastuzumab products (Revised)
Humana·Effective Jan 1, 2026
Humana revised its Trastuzumab product prior authorization policy effective January 1, 2026, with updates implemented September 1, 2026. The policy now applies to seven trastuzumab biosimilars and the reference drug across Medicaid plans in Florida, Kentucky, and South Carolina for breast cancer and gastric cancer treatment. Key change: For non-Florida Medicaid members requesting branded trastuzumab products (Herceptin, Ogivri, Herzuma, Hercessi, Ontruzant), documented intolerance or contraindication to biosimilars Trazimera or Kanjinti is now required before approval; Florida Medicaid is exempt from this requirement.
Medium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Indiana has issued a new prior authorization policy (effective September 1, 2026) for Zynlonta™ (loncastuximab tesirine-Ipyl), a CD19-directed antibody-alkylating agent conjugate for relapsed/refractory B-cell lymphomas. Billing teams must implement prior authorization requirements before dispensing this drug, ensuring patients meet strict clinical criteria: diagnosis of DLBCL or HGBL, relapsed/refractory disease, 2+ prior systemic therapy lines, and single-agent use. Claims submitted without prior authorization will be denied.
Medium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Louisiana has released a new prior authorization policy for Zynlonta (loncastuximab tesirine-Ipyl), effective September 1, 2026. The drug is now covered for adult patients with relapsed/refractory large B-cell lymphoma (DLBCL or HGBL) who have received two or more prior lines of systemic therapy and are using Zynlonta as monotherapy. All claims for this drug require prior authorization before dispensing.
Medium impact
Zynlonta™ (loncastuximab tesirine-Ipyl) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid (Ohio) has established a new prior authorization policy for Zynlonta (loncastuximab tesirine-Ipyl), effective September 1, 2026. This CD19-directed antibody-alkylating agent conjugate is now covered for relapsed/refractory B-cell lymphomas (DLBCL and HGBL) in adult patients with 2+ prior lines of systemic therapy, when used as monotherapy. Billing team must implement prior authorization requirements and ensure claims meet all four clinical criteria before submission.
High impact
Yervoy® (ipilimumab) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Indiana has implemented a new prior authorization policy for Yervoy (ipilimumab) effective September 1, 2026, covering seven cancer indications including melanoma, renal cell carcinoma, colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer. The policy establishes specific clinical criteria, approval durations (initial and renewal), and exclusions for each indication. Billing teams must implement prior authorization requirements before this date to ensure claims are not denied.
High impact
Yervoy® (ipilimumab) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Louisiana has implemented a NEW prior authorization policy for Yervoy (ipilimumab) effective September 1, 2026, covering seven cancer indications (melanoma, RCC, MSI-H colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer). The policy establishes specific clinical criteria for initial approval and renewal, with most indications requiring combination therapy with Opdivo (nivolumab) and maximum 4-month authorization periods. Billing teams must immediately identify Yervoy claims and implement prior authorization workflows before the effective date.
High impact
Yervoy® (ipilimumab) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Ohio has released a NEW prior authorization policy for Yervoy (ipilimumab) effective September 1, 2026, covering seven cancer indications including melanoma, renal cell carcinoma, colorectal cancer, hepatocellular carcinoma, NSCLC, mesothelioma, and esophageal cancer. All Yervoy requests require prior authorization with specific clinical criteria, performance status requirements (ECOG 0-2), and approval durations capped at 4 months per authorization cycle.
Medium impact
Waskyra (etuvetidigene autotemcel) - Medicare Advantage (New)
Humana·Effective Sep 1, 2026
Humana Medicare Advantage has introduced a new coverage policy for Waskyra (etuvetidigene autotemcel), an autologous gene therapy for pediatric and adult patients with Wiskott-Aldrich Syndrome (WAS) who lack suitable HLA-matched donors. Coverage requires medical director review and strict criteria compliance, with specific exclusions for patients who are pregnant, breastfeeding, or unwilling to use contraception.
Medium impact
Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (New)
Humana·Effective Sep 1, 2026
Humana Medicaid Ohio is implementing a new prior authorization policy for Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc), effective September 1, 2026. Coverage requires prior auth approval based on diagnosis confirmation (gMG or CIDP), specific antibody testing or nerve conduction studies, and specialist supervision. This is a completely new policy creating new billing and authorization workflows for these specialty neurology drugs.
High impact
Trastuzumab products (New)
Humana·Effective Sep 1, 2026
Humana has implemented a new prior authorization policy for trastuzumab products (7 biosimilar and brand-name formulations) effective September 1, 2026, covering breast cancer, gastric cancer, and other medically accepted uses. The policy establishes preferred products by Medicare coverage type (Part B prefers Trazimera/Ogivri; Part D prefers Trazimera/Kanjinti) and requires prior auth for non-preferred products unless the member has documented intolerance/contraindication, with no step therapy requirement for continuation therapy within 365 days.
High impact
Medi-Cal Hospice Program Attestation Now Available in the Provider Portal
Medi-Cal·Effective Sep 1, 2026
Medi-Cal hospice providers must now submit a Medi-Cal Hospice Attestation through the Provider Portal within 5 calendar days of members electing hospice services. The signed DHCS 8052 form must be retained in the member's medical record but is not submitted to DHCS; attestation in the portal serves as the official notice to the Department of Health Care Services.
Medium impact
New Long-Term Care (LTC) Web Portal Admission Notification Panel
Alabama Medicaid·Effective Sep 1, 2026
Alabama Medicaid has launched a new Long-Term Care (LTC) Web Portal Admission Notification Panel effective 9/1/2026, providing a streamlined, web-based alternative to current LTC admission notification software. This new portal is available at no charge to Type 3 (Nursing Homes/Hospital Swing Beds), Type 68 (PACE), and Type 53 (Waiver) providers, offering improved data validation, faster processing, and reduced administrative burden for LTC admission submissions.
High impact
[Georgia] September 2026 Provider Newsletter
Anthem BCBS·Identified Sep 2, 2026
This September 2026 Georgia provider newsletter consolidates multiple policy updates across clinical guidelines, prior authorization requirements, reimbursement policies, and pharmacy programs, with effective dates ranging from October 2026 through January 2027. The billing team must track multiple concurrent changes including new prior authorization requirements, clinical criteria updates, reimbursement policy modifications for laboratory services and facility claims, and pharmacy program changes.
High impact
[Virginia] September 2026 Provider Newsletter
Anthem BCBS·Identified Sep 2, 2026
This September 2026 Virginia provider newsletter from Anthem Blue Cross Blue Shield contains multiple policy updates across administrative, clinical, pharmacy, and prior authorization areas with staggered effective dates from October 2026 through January 2027. Key changes include new modifier 25 billing requirements for E&M services (effective November 1, 2026 for Medicaid), prior authorization requirements for specific procedures, clinical guideline updates, and new reimbursement policies for laboratory service modifiers 90 and 91 (effective December 1, 2026).
High impact
[Ohio] September 2026 Provider Newsletter
Anthem BCBS·Identified Sep 2, 2026
This September 2026 Ohio provider newsletter contains multiple policy updates affecting billing, prior authorization, reimbursement, and clinical guidelines across commercial, Medicare Advantage, and Medicaid plans. Key changes include new modifier requirements for E&M services (effective December 1, 2026 for Medicaid), laboratory service reimbursement policies for modifiers 90/91 (effective December 1, 2026), facility guidelines updates (effective December 1, 2026 for Commercial), and prior authorization requirement changes across multiple plan types.
High impact
[New York] September 2026 Provider Newsletter
Anthem BCBS·Identified Sep 2, 2026
This September 2026 New York provider newsletter contains multiple policy updates across administrative, clinical, reimbursement, and prior authorization areas, with multiple effective dates ranging from October 1, 2026 through January 1, 2027. Key changes include new modifier 25 billing requirements for Medicaid (effective October 1, 2026), updated claims editing for outpatient facilities (effective October 1, 2026), new reimbursement policies for moderate sedation and laboratory service modifiers (effective October 1 and December 1, 2026), and Medicaid 2027 work requirements (effective January 1, 2027).
High impact
[California] September 2026 Provider Newsletter
Anthem BCBS·Identified Sep 2, 2026
This September 2026 provider newsletter from Anthem Blue Cross contains multiple policy updates across billing codes, prior authorization, reimbursement, and administrative processes. Key changes include: modifier 25 billing requirements for E&M services with XXX procedures (effective Oct 1, 2026 for Medicaid), blood product administration billing consolidation (effective Dec 1, 2026), new laboratory service modifier policies (effective Dec 1, 2026), and treatment room reimbursement updates (effective Dec 1, 2026). The newsletter also announces Medicaid 2027 work requirements effective January 1, 2027, and various administrative updates across plan types.
High impact
[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross Medi-Cal is implementing a new combined reimbursement policy for laboratory modifiers 90 and 91 effective December 1, 2026. Modifier 90 (pass-through lab billing) will no longer be reimbursed except in specific circumstances (outside lab services billed by another provider using HCPCS S3620 or CPT 81528, or pathology services). Modifier 91 (repeat lab tests) remains eligible for reimbursement at 100% of fee schedule. The existing modifier 91 policy (G-06020) will be retired and consolidated into the new policy (G-20001).
High impact
[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem BCBS·Effective Dec 1, 2026
Anthem Blue Cross is implementing a new combined reimbursement policy for laboratory service modifiers 90 and 91, effective December 1, 2026. Modifier 90 (pass-through laboratory billing) is now NON-REIMBURSABLE for professional and outpatient facility providers—the performing provider must bill directly for 100% reimbursement. Modifier 91 (repeat clinical diagnostic lab tests) remains eligible for reimbursement at 100% on professional claims. The existing modifier 91 policy (G-06020) will be retired.
Low impact
[California] Improve respiratory outcomes through proactive care
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross Medicare Advantage in California is issuing a provider bulletin emphasizing proactive management of respiratory diseases (asthma and COPD) to reduce preventable emergency visits and hospitalizations. This is an educational/clinical guidance update rather than a billing policy change, highlighting the importance of medication adherence, controller therapy gaps, inhaler technique assessment, and preventive care coordination.
Low impact
[California] Skai Blue Cross Blue Shield, a new third-party administrator of Arkansas Blue Cross Blue Shield
Anthem BCBS·Effective Jan 1, 2026
Arkansas Blue Cross Blue Shield has launched Skai Blue Cross Blue Shield, a new third-party administrator brand for national account groups effective January 1, 2026. Members with Skai-branded ID cards should be treated identically to standard Blue Cross Blue Shield members with no changes to billing, eligibility verification, or cost-sharing requirements.
Medium impact
[California] Manage behavioral health Peer-to-Peer conversations online
Anthem BCBS·Effective Sep 1, 2026
Anthem Blue Cross is launching a new online scheduling feature within Availity Essentials that allows providers to schedule and cancel Peer-to-Peer (P2P) conversations electronically, replacing the current phone and email submission process. This change applies across Commercial, Medicare Advantage, and Medicaid plans in California and offers 24/7 self-service scheduling with real-time visibility into appointments.
Medium impact
[California] Medicaid 2027 work requirements: What care providers need to know
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, certain Medi-Cal (California Medicaid) members ages 19-64 in the expansion population must report an average of 80 hours per month of work, school attendance, community service, or a combination thereof to maintain eligibility. Members must also renew benefits more frequently. Most Medi-Cal members are exempt, including pregnant/postpartum women, caregivers, medically frail individuals, disabled veterans, and foster youth. Eligibility will be verified using available data sources when possible; members unable to be verified will receive direct communication requiring manual reporting.
Low impact
[California] Help patients get the most from vaginal estrogen therapy
Anthem BCBS·Identified Sep 2, 2026
Anthem Blue Cross (California Medicare Advantage) has issued patient education guidance on proper vaginal estrogen cream application for treating recurrent UTIs in peri- and postmenopausal women. This is an informational bulletin recommending providers counsel patients on correct applicator use and finger application technique to improve treatment outcomes and reduce medication waste. No billing, coverage, or reimbursement changes are specified.

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Archive by year

2023 2024 2025 2026

Zurzuvae® (zuranolone) (Revised)

Trastuzumab products (Revised)

Zynlonta™ (loncastuximab tesirine-Ipyl) (New)

Zynlonta™ (loncastuximab tesirine-Ipyl) (New)

Zynlonta™ (loncastuximab tesirine-Ipyl) (New)

Yervoy® (ipilimumab) (New)

Yervoy® (ipilimumab) (New)

Yervoy® (ipilimumab) (New)

Waskyra (etuvetidigene autotemcel) - Medicare Advantage (New)

Vyvgart® (efgartigimod alfa-fcab) & Vyvgart® Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (New)

Trastuzumab products (New)

Medi-Cal Hospice Program Attestation Now Available in the Provider Portal

New Long-Term Care (LTC) Web Portal Admission Notification Panel

[Georgia] September 2026 Provider Newsletter

[Virginia] September 2026 Provider Newsletter

[Ohio] September 2026 Provider Newsletter

[New York] September 2026 Provider Newsletter

[California] September 2026 Provider Newsletter

[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[California] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services

[California] Improve respiratory outcomes through proactive care

[California] Skai Blue Cross Blue Shield, a new third-party administrator of Arkansas Blue Cross Blue Shield

[California] Manage behavioral health Peer-to-Peer conversations online

[California] Medicaid 2027 work requirements: What care providers need to know

[California] Help patients get the most from vaginal estrogen therapy