Medical Policy Updates for November 2026

By September 1, 2026: Billing team must update all billing software and clearinghouse settings to require prior authorization for the following pharmacy policies effective September 15, 2026: Policy 004 (Immune Modulating Drugs - Skyrizi, Xeljanz), Policy 013 (Anti-Hyperlipidemics - Repatha, Praluent, Leqvio, Lerochol, Tyngolza), Policy 017 (Injectable Asthma - Exdensur, Fasenra), Policy 033 (MED UM & Pharmacy - Forzinity, Osvyrti, Jubereq), Policy 041 (Diabetes Step Therapy - generic Januvia and Janumet now require Step 2 therapy), Policy 049 (Drug Management - Jascayd, Palsonify), Policy 093 (Complement disorders - Vyvgart/Vyvgart Hytrulo), Policy 105 (Cancer supportive care - Armlupeg, Filkri), and Policy 346 (Ophthalmic - Rescula removed from market, no longer billable). Providers and staff must be notified of new step therapy requirements for diabetes medications. Update all prior authorization submission processes and encounter forms. Claims submitted without required prior authorization will be denied. Additionally, by August 22, 2026, update system alerts regarding Category III CPT codes to reflect that all 2026 Category III codes are non-covered unless explicitly listed as medically necessary in a BCBSMA policy—staff must verify coverage via https://www.bluecrossma.org/medical-policies/ before billing.