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Medical Policy Updates for August 2026
Effective date
Not stated in the notice
Identified
Jun 20, 2026
Summary
Blue Cross Blue Shield of Massachusetts medical policy changes carry effective dates of May 1, 2026, July 1, 2026, August 1, 2026 and September 19, 2026, all of which have now passed. Key changes include new prior authorization for Tyruko under Medicare Advantage Part B, prior authorization and step therapy updates across several commercial drug policies, and a move of brand Hetlioz and brand Aubagio to non-formulary, non-covered status in favor of generic tasimelteon and teriflunomide. Imaging, sleep, genetic testing and radiation therapy guidelines were also revised, and HCPCS code G0680 was added as investigational.
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What to do
Action · 19 steps
01Already effective May 1, 2026, Commercial: prior authorization is required for Rybrevant Faspro (Carelon Oncology Program), for Anzupgo and the Zoryve cream prerequisites (Immunomodulators for Skin Conditions, policy 010), for updated Mounjaro criteria (GLP-1 Receptor Agonists, policy 056), for Hernexeos, Modeyso and updated Jayparca criteria (Oncology Drugs, policy 409), for updated Cosentyx and Sotyktu criteria (Immune Modulating Drugs, policy 004), for Enoby, Bosaya, Aukelso and Xtrenbo, updated Dupixent and Krystexxa criteria (Medical UM and Pharmacy PA Policy, policies 033 and 034), and for Infergen removal (Interferons, policy 052).
02Step therapy is required for Sephience and Brinsupri (Drug Management and Retail Pharmacy PA Policy, policy 049).
03Already effective May 1, 2026, Medicare Advantage Part B: prior authorization is required for Tyruko (Medical Utilization Management, policy 125).
04Already effective July 1, 2026, Commercial: step therapy is required for Harliku, and prior authorization is required for the Daybue Stix formulation (policy 049).
05Rinvoq 45 mg requests carry a 16-week approval limitation and require prior authorization (Immune Modulating Drugs, policy 004).
06Brand Hetlioz moves to non-formulary and non-covered, with generic tasimelteon preferred, and prior authorization is required (policy 697).
07Brand Aubagio moves to non-formulary and non-covered, with generic teriflunomide preferred (Multiple Sclerosis Prior Auth, policy 839).
08Bruimvi, Lemtrada, Ocrevus and Ocrevus Zunovo are added to policy 839 and moved there from policies 033 and 034, with Smart PA used to determine coverage for all covered agents in the multiple sclerosis class.
09The Topical Testosterone policy (345) is retired, and prior authorization is required for Commercial products.
10Already effective August 1, 2026, Commercial and Medicare: Laser Interstitial Thermal Therapy (policy 948) changes its investigational statement to medically necessary with criteria for refractory epilepsy, malignant brain tumors and radiation necrosis, and prior authorization is not required.
11Continuous Passive Motion in the Home Setting (policy 407) adds an investigational statement for continuous passive motion with remote monitoring or adaptive capabilities, and prior authorization is not required.
12Medical Technology Assessment policy 400 adds HCPCS G0680 as investigational, with no action required.
13A new Radiation Therapy for Non-Malignant Disease guideline covers arteriovenous malformations, desmoid tumors, Dupuytren-Ledderhose-Peyronie's disease, Graves' ophthalmopathy, gynecomastia, heterotopic ossification, jugular paraganglioma, keloid scar, plantar fasciitis and trigeminal neuralgia, with fraction thresholds for several conditions.
14Radiation therapy is not medically necessary for neovascular age-related macular degeneration, osteoarthritis or refractory ventricular tachycardia.
15All Category III CPT codes, including the new 2026 codes, are non-covered unless a BCBSMA medical policy explicitly describes them as medically necessary; if there is no associated policy, the code is non-covered.
16Already effective September 19, 2026, Carelon Guidelines: imaging guideline updates include expanded CT cerebral perfusion indications, allowances for CTA head and neck codes, duplex ultrasound required before CTA or MRA for stroke or TIA symptoms present more than 30 days, and surveillance criteria after endovascular repair.
17Sleep disorder management removes the respiratory disturbance event definition and expands contraindications to home sleep apnea testing.
18Genetic testing requires testing in a CLIA-certified laboratory accredited by the College of American Pathologists, and biomarker testing for rejection in solid organ transplantation is allowed beginning 2 months after cardiac transplant.
19Since all dates listed have passed, confirm current applicability of each change before acting.
Codes mentioned
G0680
Original notice
Medical Policy Updates for August 2026
bluecrossma.org · Always check the source before changing claims.