CommercialPrior AuthHigh impact
Medical Policy Updates for April 2026
Blue Cross Blue Shield of Massachusetts·Gastroenterology, Orthopedics, Neurology·Medical Policy
Effective date
Apr 1, 2026
We identified it
Jun 20, 2026
Summary
Multiple policy changes affecting gastroenterology, orthopedics, neurology, and pharmacy services effective April 1, 2026, and January 2026. Key changes include new medical policies for spine fusions and joint replacements replacing InterQual criteria, new step therapy requirements for denosumab drugs, and addition of multiple new drugs requiring prior authorization.
Action Required
By April 1, 2026: Update prior authorization workflows for spine fusion (Policy 226) and total joint replacement procedures (Policy 228) - new medical policies will replace InterQual criteria for commercial plans. Immediately: Implement step therapy requirements for denosumab drugs (Prolia/biosimilars) with oral bisphosphonates as Step 1, requiring prior auth for Steps 2-3. Update billing system to require prior authorization for newly added drugs including Cimzia, Ilumya, Tremfya, Zevaskyn, and multiple other medications listed in pharmacy policies. Train staff on new drug formulary requirements and step therapy protocols.