All Insurance Policy Changes (Page 7)

Continuing from page 6. 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
Check Fax Settings To Ensure You Receive Our Communications
HealthSpring·Identified Sep 11, 2026
HealthSpring has issued a notice that incoming faxes to provider offices may be blocked by security systems or fax filters. Providers must add five HealthSpring fax numbers to their approved/safe sender lists to ensure receipt of important communications from the payer.
High impact
Prior Authorization Changes Effective Oct. 1 and Nov. 1, 2026
HealthSpring·Effective Oct 1, 2026
HealthSpring Medicare Advantage is changing prior authorization requirements for HealthSpring and EviCore, effective in two phases: Oct. 1, 2026 (removal/replacement of oncology codes, removal of immunology and molecular diagnostic codes from HealthSpring review) and Nov. 1, 2026 (addition of oncology drug codes to EviCore review). Billing teams must verify current prior authorization requirements through Availity Essentials before rendering services, as claims without required prior auth will be denied.
Medium impact
Justice-Involved (JI) Reentry Initiative: New Aid Codes for Members with UIS Coming Soon
Medi-Cal·Effective Jan 1, 2027
Effective January 1, 2027, Medi-Cal will implement new aid codes for members with Unsatisfactory Immigration Status (UIS) who are part of the Justice-Involved (JI) Reentry Initiative. These members will transition from managed care to fee-for-service coverage, remain eligible for full-scope Medi-Cal benefits, but will lose access to Enhanced Care Management and Community Support services. Billing teams must prepare to identify and process claims for these new aid codes separately from managed care claims.
Medium impact
November 2026 Updates to the Medi-Cal List of Contracted Incontinence Creams and Washes
Medi-Cal·Effective Nov 1, 2026
Effective November 1, 2026, the California Department of Health Care Services (DHCS) will update the Medi-Cal List of Contracted Incontinence Creams and Washes based on an annual review. This change applies only to fee-for-service Medi-Cal members; managed care members must follow their individual plan formularies. The specific product list changes will be released in a future Medi-Cal Update.
Medium impact
[New York] Precertification/prior authorization list change notification
Anthem BCBS·Effective Jan 1, 2027
Anthem Blue Cross and Blue Shield is adding five CPT codes and one HCPCS code related to Dichoptic Digital Therapy for Amblyopia to their prior authorization requirements, effective January 1, 2027. All services using codes 0687T, 0688T, 0704T, 0705T, 0706T, and A9292 will now require precertification before service delivery to ensure coverage eligibility and compliance with clinical guidelines.
Medium impact
[Virginia] Precertification/prior authorization list change notification
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield (Virginia) is adding Dichoptic Digital Therapy for Amblyopia (CPT codes 0687T, 0688T, 0704T, 0705T, 0706T, and HCPCS A9292) to its precertification/prior authorization requirements. Providers must obtain prior authorization before rendering these services or claims may be denied as ineligible for payment.
Medium impact
[Georgia] Precertification/prior authorization list change notification
Anthem BCBS·Effective Jan 1, 2027
Effective January 1, 2027, Anthem Blue Cross and Blue Shield in Georgia is adding five CPT codes (0687T, 0688T, 0704T, 0705T, 0706T) and one HCPCS code (A9292) for Dichoptic Digital Therapy for Amblyopia to their precertification/prior authorization requirements under clinical criteria CG-MED-102. All services using these codes will require prior authorization before delivery to avoid claim denials.
Low impact
CQV/CCA Webinars
Ambetter·Identified Sep 10, 2026
Centene/Ambetter Health is promoting two new provider tools: Clinical Quality Validation (CQV) for electronically submitting HEDIS quality care gap documentation, and Clinical Action (CCA) for viewing members' HEDIS measures status and claim-related clinical data. Providers should access these on-demand webinars at Essentials.Availity.com to learn navigation and improve quality measure compliance.
Low impact
Pivekimab Sunirine-pvzy (Decnupaz™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Pivekimab Sunirine-pvzy (Decnupaz™), a newly FDA-approved treatment for blastic plasmacytoid dendritic cell neoplasm (BPDCN) in adult patients. The policy requires prior authorization with confirmed BPDCN diagnosis documentation and covers up to 12 months of single-agent therapy, with reauthorization available if there is no disease progression or unacceptable toxicity.
Medium impact
Allogeneic Regulatory T Cell Immunotherapy with HSPC and T cells-vldq (Tregzi™)
BCBS Tennessee·Effective Sep 30, 2026
BlueCross BlueShield of Tennessee is introducing a new medical policy for Tregzi™ (allogeneic regulatory T cell immunotherapy), a newly FDA-approved drug for preventing chronic graft-versus-host disease in hematological malignancy patients undergoing matched donor hematopoietic stem cell transplantation. The policy establishes strict coverage criteria, requires prior authorization for a single 3-month dose, and will not take effect until September 30, 2026.
Medium impact
Vedolizumab (Entyvio®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Vedolizumab (Entyvio®) effective December 1, 2026, establishing coverage criteria for four indications: moderately to severely active ulcerative colitis and Crohn's disease (12-month authorization), immune checkpoint inhibitor-related toxicity (6-month authorization), acute graft versus host disease (12-month authorization), and CAR T-cell-related toxicity (6-month authorization). The policy requires prior authorization, specific prescriber specialties, detailed documentation of clinical response for continuation, and prohibits concomitant use with other biologic or targeted synthetic drugs for the same indication.
High impact
Ustekinumab Products: Ustekinumab (Stelara®); Ustekinumab-auub (Wezlana™); Ustekinumab-srlf (Imuldosa™); Ustekinumab-aauz (Otulfi™); Ustenkinumab-ttwe (Pyzchiva™), Ustekinumab-aekn (Selarsdi™); Ustenkinumab-stba (Steqeyma™); Ustenkinumba-kfce (Yesintek™); ustekinumab; ustekinumab-aauz, ustekinumab-stba, ustekinumab-aekn ; ustekinumab-auub; ustenkinumabttwe, Ustekinumab-hmny (Starjemza)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee issued a new medical policy covering ustekinumab and its biosimilar products (Wezlana, Imuldosa, Otulfi, Pyzchiva, Selarsdi, Steqeyma, Yesintek, Starjemza) for plaque psoriasis, psoriatic arthritis, Crohn's disease, ulcerative colitis, and immune checkpoint inhibitor-related toxicity. The policy establishes specific coverage criteria, documentation requirements, prescriber specialty restrictions, and prior authorization timelines. This policy is not to be implemented until December 1, 2026.
Medium impact
Triptorelin Pamoate (Trelstar®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Triptorelin Pamoate (Trelstar®) covering FDA-approved and compendial uses including prostate cancer, breast cancer ovarian suppression, ovarian function preservation, salivary gland tumors, uterine sarcoma, and gender dysphoria. The policy requires prior authorization with specific approval criteria and documentation requirements for each indication. Policy is effective December 1, 2026, and is not yet implemented.
Medium impact
Toripalimab-tpzi (Loqtorzi)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy covering Toripalimab-tpzi (Loqtorzi), an immunotherapy drug approved for nasopharyngeal carcinoma and several other cancers. The policy establishes coverage criteria, prior authorization requirements, and continuation of therapy guidelines across seven indicated diagnoses. This policy is NOT YET EFFECTIVE and should not be implemented until December 1, 2026.
Medium impact
Tezepelumab-ekko (Tezspire®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is implementing a new medical policy for Tezepelumab-ekko (Tezspire®) covering severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) in patients 12 years and older. The policy requires prior authorization, specific clinical criteria, specialist prescribing, and concurrent use of maintenance therapies. This policy is not yet effective and should not be implemented before December 1, 2026.
Medium impact
Telisotuzumab vedotin-tllv (Emrelis™)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Telisotuzumab vedotin-tllv (Emrelis™), a targeted cancer therapy for advanced non-squamous NSCLC with high c-Met protein overexpression. The policy covers the drug as a single agent for patients with EGFR wild-type tumors who have received prior systemic therapy, requiring prior authorization with specific genetic testing documentation. This policy becomes effective December 1, 2026.
Medium impact
Tarlatamab-dlle (Imdelltra™)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Tarlatamab-dlle (Imdelltra™) effective December 1, 2026. The policy covers this medication for adult patients with extensive stage small cell lung cancer (ES-SCLC) with disease progression after platinum-based chemotherapy, with 12-month authorization periods for initial and continued therapy. All other indications are considered experimental/investigational and non-covered.
Medium impact
Sebelipase Alfa (Kanuma®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new prior authorization and coverage policy for Sebelipase Alfa (Kanuma®) for treatment of Lysosomal Acid Lipase (LAL) deficiency. The policy requires documented enzyme assay or genetic confirmation of LAL deficiency, elevated ALT levels (≥1.5x upper limit of normal on two consecutive measurements), clinical disease signs, and prescriber specialization in metabolic/lysosomal storage disorders. Initial authorizations are granted for 12 months with continuation based on documented therapeutic response.
Medium impact
Risankizumab-rzaa (Skyrizi®)
BCBS Tennessee·Effective Dec 1, 2026
This is a NEW medical policy for Risankizumab-rzaa (Skyrizi®) establishing coverage criteria, prior authorization requirements, and documentation standards for four FDA-approved indications: plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis. The policy requires specific prescriber specialties, TB screening documentation, and evidence of clinical response for continuation of therapy. Implementation is prohibited until December 1, 2026.
Medium impact
Reslizumab (Cinqair®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is implementing a new coverage policy for Reslizumab (Cinqair®) for severe eosinophilic asthma in adults 18+. The policy establishes prior authorization requirements, clinical criteria (eosinophil count ≥400 cells/mcL or systemic corticosteroid dependence plus uncontrolled asthma), prescriber specialty restrictions (allergist/immunologist or pulmonologist only), and a dosing limit of 3mg/kg IV every 4 weeks. Initial authorizations are granted for 6 months, with continuation authorizations for 12 months if asthma control improves.
Medium impact
Ranibizumab (Susvimo®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new medical policy for Ranibizumab (Susvimo®), an ocular implant for three retinal conditions (wet AMD, diabetic macular edema, and diabetic retinopathy). Coverage requires prior step therapy, documented response to at least two prior VEGF inhibitor injections, and ophthalmologist prescription. The policy becomes effective December 1, 2026 and authorizes 12-month treatment periods with continuation based on demonstrated clinical response.
Medium impact
Pegunigalsidase Alfa-iwxj (Elfabrio®)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee is establishing a new prior authorization policy for Pegunigalsidase Alfa-iwxj (Elfabrio®), a enzyme replacement therapy for adult Fabry disease patients. Coverage requires confirmed diagnosis via enzyme assay or genetic testing, documented clinical symptoms, specialist prescribing, and no concurrent use with competing therapies. Authorization periods are 12 months with continuation based on documented therapeutic response.
Medium impact
Pasireotide (Signifor® LAR)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Pasireotide (Signifor® LAR) effective December 1, 2026, establishing coverage criteria for acromegaly and Cushing's disease treatment. The policy requires step therapy, specific laboratory documentation for initial and continuation approvals, and limits authorization to 12-month periods. All prior authorization requests must include documented evidence of inadequate surgical response or surgical ineligibility, plus baseline hormone level testing.
High impact
Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)
BCBS Tennessee·Effective Dec 1, 2026
This is a new medical policy for Omalizumab products (Xolair® and Omlyclo®) covering four FDA-approved indications (asthma, chronic rhinosinusitis with nasal polyps, IgE-mediated food allergy, and chronic spontaneous urticaria) plus two compendial uses. The policy establishes specific prior authorization requirements, documentation standards, prescriber specialty requirements, and coverage criteria for each indication. Implementation is not required until December 1, 2026.
High impact
Nusinersen (Spinraza™)
BCBS Tennessee·Effective Dec 1, 2026
BlueCross BlueShield of Tennessee has issued a new medical policy for Nusinersen (Spinraza™) covering treatment of spinal muscular atrophy (SMA). The policy establishes comprehensive coverage criteria requiring prior authorization, genetic testing confirmation (≤3 SMN2 gene copies), neurologist prescription, baseline laboratory tests, and documented motor/respiratory function. The policy is NOT YET EFFECTIVE and must not be implemented until December 1, 2026.

Browse by payer Browse by state Browse by specialty Browse by billing code Browse & filter all changes

Get alerts for changes like this

Save a search and receive a daily digest whenever a new policy change matches your filters.

Create a free alert

Archive by year

2023 2024 2025 2026

Check Fax Settings To Ensure You Receive Our Communications

Prior Authorization Changes Effective Oct. 1 and Nov. 1, 2026

Justice-Involved (JI) Reentry Initiative: New Aid Codes for Members with UIS Coming Soon

November 2026 Updates to the Medi-Cal List of Contracted Incontinence Creams and Washes

[New York] Precertification/prior authorization list change notification

[Virginia] Precertification/prior authorization list change notification

[Georgia] Precertification/prior authorization list change notification

CQV/CCA Webinars

Pivekimab Sunirine-pvzy (Decnupaz™)

Allogeneic Regulatory T Cell Immunotherapy with HSPC and T cells-vldq (Tregzi™)

Vedolizumab (Entyvio®)

Triptorelin Pamoate (Trelstar®)

Toripalimab-tpzi (Loqtorzi)

Tezepelumab-ekko (Tezspire®)

Telisotuzumab vedotin-tllv (Emrelis™)

Tarlatamab-dlle (Imdelltra™)

Sebelipase Alfa (Kanuma®)

Risankizumab-rzaa (Skyrizi®)

Reslizumab (Cinqair®)

Ranibizumab (Susvimo®)

Pegunigalsidase Alfa-iwxj (Elfabrio®)

Pasireotide (Signifor® LAR)

Omalizumab Products: Omalizumab (Xolair®); Omalizumab-igec (Omlyclo®)

Nusinersen (Spinraza™)