What insurance policy changes affect Internal Medicine providers?

Internal Medicine providers face policy updates from major payers including prior authorization requirements, billing code changes, reimbursement rate adjustments, and coverage criteria revisions. PolicyChanges.app tracks these updates daily across all major insurers.

How often do insurance policies change for Internal Medicine?

Insurance payers publish policy changes on rolling schedules: some quarterly, some monthly, and some with immediate effect. Internal Medicine practices typically see dozens of relevant changes per year across their contracted payers.

How do I get notified of new Internal Medicine policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to Internal Medicine. You will get an email when new policy changes match your specialty filter: daily or weekly, your choice, on every plan.

Which payers post the most policy changes affecting Internal Medicine?

Based on tracked changes, Internal Medicine updates have come from payers including Anthem BCBS, Independence Blue Cross, HMSA, UnitedHealthcare.

PAYER POLICY CHANGES

Internal Medicine Insurance Policy Changes

Keeping up with insurance policy changes that affect Internal Medicine practices is a full-time job. This page aggregates the latest payer updates (prior authorization rule changes, reimbursement adjustments, billing code additions and removals, and coverage policy revisions) across all major insurers. Changes are identified and summarized daily so Internal Medicine providers and their billing teams can act before deadlines pass.

Anthem BCBS · Effective Nov 29, 2026High impact
[New York] Clinical Criteria updates
Anthem has revised 60 clinical criteria policies for medical drug benefits under Medicare Advantage plans, effective November 29, 2026. These revised criteria may affect prior authorization requirements, medical necessity determinations, and billing for a broad range of specialty pharmaceuticals including biologics, oncology agents, and rare disease treatments. The practice should review the full policy text for each affected drug to understand specific changes to clinical coding edits and authorization rules.
Anthem BCBS · Effective Nov 29, 2026High impact
[Virginia] Clinical Criteria updates
Anthem Blue Cross and Blue Shield has revised 60 clinical criteria policies for medical drug benefits effective November 29, 2026. These revisions affect medical necessity requirements for specialty pharmaceuticals across multiple therapeutic categories including oncology agents, biologics, growth hormones, and rare disease treatments. Billing and clinical teams must review updated criteria in the Clinical Criteria page and coordinate with authorization requirements communicated separately.
Independence Blue Cross · Effective Nov 30, 2026High impact
MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring
Effective 11/30/2026, Independence Blue Cross Medicare Advantage is updating medical policy MA12.010e to change remote patient monitoring (RPM and RTM) coverage from a blanket covered status to medically necessary with specific criteria. Coverage is now limited to patients with heart failure, hypertension, or diabetes mellitus, with 16 CPT/HCPCS codes now eligible only when specific diagnoses and clinical criteria are met. Billing teams must update authorization logic, documentation requirements, and claim submission workflows to reflect the new diagnosis-based eligibility rules.
HMSA · Effective Dec 1, 2026High impact
HealthPro News – October 2026
HMSA's October 2026 provider newsletter, issued Oct. 1, 2026, lists several changes with different dates. Effective Jan. 1, 2027, HMSA will no longer cover Transitional Care Management (TCM) codes 99495 and 99496 for commercial and QUEST members, while TCM remains a covered benefit for Medicare members when CMS requirements are met. Effective Dec. 1, 2026, commercial plans will require blood and blood products to be billed with Revenue Code 038X and the applicable HCPCS code, and blood processing and storage services with Revenue Code 039X.
UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for New Mexico Only)
UnitedHealthcare Community Plan of New Mexico (Medicaid) is revising its cardiovascular disease risk testing policy effective December 1, 2026. The policy narrows coverage by removing lipoprotein(a) testing from the unproven list (making it potentially coverable) while adding noninvasive point-of-care cardiac platforms like CorVista System to the non-covered list, and updating applicable CPT codes with a new quarterly edit code (1104T) and removal of code 83695.
UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for New Jersey Only)
UnitedHealthcare Community Plan of New Jersey (Medicaid) revised its coverage policy for cardiovascular disease risk tests, effective December 1, 2026. The policy narrowed the exclusion for advanced lipoprotein analysis (now excluding only subfractions/particle size, not lipoprotein(a)), added exclusion for noninvasive point-of-care cardiac diagnostic platforms using machine learning (e.g., CorVista System), updated applicable CPT codes, and removed CPT 83695 from the billable codes list.
UnitedHealthcare · Effective Dec 1, 2026High impact
Cardiovascular Disease Risk Tests (for Kentucky Only)
UnitedHealthcare Kentucky Medicaid updated its cardiovascular disease risk testing policy effective December 1, 2026, narrowing coverage exclusions for lipoprotein analysis and adding new non-covered technologies including CorVista cardiac diagnostic platforms. CPT code 83695 was removed from the policy, and the policy now references Kentucky state statutes for medical necessity determination. Billing teams must immediately update denial logic and prior authorization workflows to reflect these changes.
UnitedHealthcare · Effective Dec 1, 2026High impact
Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)
UnitedHealthcare Community Plan of Kentucky (Medicaid) revised its breast imaging policy effective December 1, 2026, clarifying coverage criteria for MRI breast screening in high-risk individuals while designating several advanced imaging modalities (including Molecular Breast Imaging for routine screening and Positron Emission Mammography) as unproven and not medically necessary. The policy removed the standalone BSGI definition and refined language around MRI indications, genetic risk criteria, and age thresholds for screening initiation.
Harvard Pilgrim Health Care · Effective Dec 1, 2026High impact
Laboratory Payment Policies: Dec. 1, 2026 updates
Point32Health/Harvard Pilgrim Health Care is adding new CPT codes to four laboratory testing policies effective December 1, 2026. Billing teams must update their systems to recognize and process these newly covered codes: 0421U for colorectal cancer screening, 82950 for diabetes testing, 87638 for microorganism identification, and 87627, 0600U, 0601U, and 0610U for pathogen panel testing.
Capital Blue Cross · Effective Dec 1, 2026High impact
AB2026-10-002 Medicare only
Capital Blue Cross is implementing significant updates to Medicare Advantage plans effective January 1, 2027, including plan county changes, revised medical and pharmacy benefits, elimination of OTC hearing aid coverage, and new clinical guidelines. Additionally, new prior authorization requirements for specific oncology drugs (Bortezomib and Pemetrexed codes) take effect December 1, 2026.
CareSource · Effective Dec 1, 2026High impact
[Ohio] Avalon Policy Updates
CareSource Ohio Medicaid has partnered with Avalon Healthcare Solutions for laboratory benefits management and is revising 36 laboratory reimbursement policies effective December 1, 2026. These revised policies govern routine lab testing through Avalon's post-service pre-payment clinical claim editing program (RTM). No prior authorization requirement changes are indicated, but billing teams must ensure compliance with updated lab policies on Avalon's website to avoid claim denials.
Aetna Better Health of Virginia · Effective Dec 1, 2026High impact
Provider Notification - New Policy Updates - Clinical Payment, Coding, and Policy Changes Effective December 1, 2026
Effective December 1, 2026, Aetna Better Health of Virginia is implementing new age-based eligibility requirements for specific CPT and HCPCS codes under VA Medicaid. Claims will be automatically denied if the member's age falls outside the specified ranges for ESRD dialysis codes (CPT 90957-90970), preventative care codes (CPT 99386-99397), and injectable medications (HCPCS J1307, J3387, J3391). Billing teams must verify member age before claim submission to avoid denials.
BCBS Tennessee · Effective Dec 1, 2026High impact
Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg)
BlueCross BlueShield of Tennessee is establishing a new medical policy for Leuprolide Acetate Depot (Lupron Depot and Lutrate Depot) covering four FDA-approved indications: advanced prostate cancer, ovarian cancer (malignant sex cord-stromal tumors), breast cancer (premenopausal with hormone-receptor positive status), and gender dysphoria. All covered uses require prior authorization with specific approval criteria, and the policy includes detailed requirements for gender dysphoria treatment involving age restrictions, provider specialization, and documented informed consent. This policy will supersede any existing guidance effective December 1, 2026.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claim forms. These services are only reimbursable when submitted by the rendering provider on CMS-1500 professional claim forms using the applicable codes. Participating providers cannot balance bill members for this change.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse outpatient medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 facility claims. These services are now eligible for reimbursement ONLY when submitted by the rendering provider on CMS-1500 (professional claim form). Billing teams must route these services to the correct claim form type to avoid denials.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements for 5 specialty pharmacy drugs effective December 1, 2026, adding quantity limits for 3 of those drugs, and revising clinical criteria for 11 existing specialty medications. Patients currently receiving these medications without prior authorization will require prior auth requests going forward. Inclusion of NDC codes on claims will expedite processing for drugs billed with NOC codes.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] New combined reimbursement policy: Modifiers 90 and 91: Laboratory Services
Anthem Medicare Advantage is implementing a new combined reimbursement policy (G-20001) effective December 1, 2026, that prohibits pass-through laboratory billing with modifier 90 on professional and outpatient facility claims—these claims will no longer be reimbursed. Providers performing lab tests must bill directly. Modifier 91 guidance for repeat clinical diagnostic laboratory tests remains unchanged and eligible for reimbursement. The previous modifier 91 policy (G-06020) will be retired.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility
Effective December 1, 2026, Anthem will no longer reimburse medical nutritional therapy (CPT 97802–97804; HCPCS G0270–G0271) and obesity counseling services (HCPCS G0421, G0447) when billed on UB-04 (facility claims). These services are now eligible for reimbursement ONLY when submitted on CMS-1500 (professional claim form) by the rendering provider. Billing teams must immediately audit billing workflows to prevent claim denials and ensure correct claim form submission.
Blue Cross Blue Shield of Vermont · Effective Dec 1, 2026High impact
Preventive Care Reminder Sent to Members
Members receive the preventive services listed here at no cost when they align with USPSTF A- and B-rated services, ACIP vaccine recommendations, HRSA infant, child, adolescent and women's preventive guidelines, and Vermont state mandates. Covered procedure and diagnosis codes are listed for screenings, counseling, vaccines and preventive medications for children, adults and pregnant members, and some services require prior approval. Recent revisions add a Pre-Diabetes Preventive Interventions section for adults 18 and older, split mammography into diagnostic, ultrasound and MRI sections, and add pregnancy diagnosis codes effective 12/01/2026.
PacificSource Health Plans · Effective Dec 22, 2026High impact
December 2026 Drug List Change Notification (Commercial)
PacificSource is implementing comprehensive drug list changes effective December 22, 2026, including 24 new formulary additions across commercial and state-based plans (OR, ID, MT, WA), updates to prior authorization criteria for 11 drug classes, and removal of prior authorization requirements for Breztri aerosol. The billing team must update prior authorization workflows, tier assignments, quantity limits, and step therapy requirements in billing systems to reflect these changes.
Medi-Cal · Effective Jan 1, 2027High impact
FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027
Effective January 1, 2027, Medi-Cal members with Unsatisfactory Immigration Status move from Medi-Cal managed care plans to Medi-Cal fee-for-service, so FQHC and RHC claims for these members must go directly to the Medi-Cal fiscal intermediary rather than to the former plan. Effective for services on or after January 1, 2027, claims sent to the former plan or to the FI for an MCP differential (wrap) rate will be denied, and from July 1, 2027, emergency and pregnancy-related services for these members are reimbursed only at the PPS rate with the appropriate diagnosis code and emergency indicator.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
Effective 2027-01-01, UnitedHealthcare Community Plan of Tennessee revised its Medicaid medical benefit policy for denosumab. Jubereq and Osvyrti are now preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred products covered only if the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The policy also adds a very-high-fracture-risk criterion for initial osteoporosis therapy and adds HCPCS codes Q5166, Q5171, and Q5173.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
Effective 2027-01-01, UnitedHealthcare Community Plan of New Mexico Medicaid expanded its denosumab policy: Jubereq and Osvyrti are preferred products covered under the Diagnosis-Specific Criteria, while Boncresa, Oziltus, and Ponlimsi are non-preferred and covered only when the Preferred Product Criteria and Diagnosis-Specific Criteria are both met. The postmenopausal osteoporosis criteria add a very-high-fracture-risk pathway for initial therapy, and HCPCS codes Q5166, Q5171, and Q5173 were added.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
UnitedHealthcare Community Plan of Kentucky's Medicaid medical policy for denosumab was revised effective 2027-01-01, updating the list of covered denosumab products by adding Boncresa, Jubereq, Osvyrti, Oziltus, and Ponlimsi, with Jubereq and Osvyrti designated preferred and Boncresa, Oziltus, and Ponlimsi designated non-preferred. Coverage for postmenopausal osteoporosis treatment was revised to add an initial-therapy criterion for very high fracture risk (a fracture in the past 12 months or a fracture while on approved osteoporosis therapy), and HCPCS codes Q5166, Q5171, and Q5173 were added. Billing staff should update product and code references and review the new very-high-risk documentation requirements before submitting denosumab claims for these members.
UnitedHealthcare · Effective Jan 1, 2027High impact
Denosumab
Effective 2027-01-01, UnitedHealthcare Community Plan (Medicaid, national) revised its denosumab medical benefit drug policy: five new biosimilars were added (Boncresa, Jubereq, Osvyrti, Oziltus, Ponlimsi), Jubereq and Osvyrti are designated preferred products, Boncresa, Oziltus and Ponlimsi are non-preferred, and HCPCS Q5166, Q5171 and Q5173 were added. The osteoporosis coverage criteria were expanded to add a very-high-fracture-risk initial therapy requirement.
UnitedHealthcare · Effective Jan 1, 2027High impact
Omnibus Codes
UMR revised its medical policy bulletin for November 2026, adding unproven/not medically necessary language for several services (including photobiomodulation for AMD, CRISPR-based TB plasma testing, Alzheimer's proprietary biomarker and genetic tests, and digital 3D models from surface mesh files) and revising criteria for IRE ablation, BeScreened-CRC, BIOTIA-ID, IVD CAPSULE PSP, histotripsy, external urine management systems, sacral Tarlov cyst surgery (now requiring failure of conservative multidisciplinary management instead of 12 weeks of non-surgical treatment), and meibomian gland procedures. The bulletin's status is revised with an effective date of 2027-01-01 for these coverage guidelines.
HealthPartners · Effective Jan 1, 2027High impact
Fast Facts Newsletter - November 2026
HealthPartners' November 2026 Fast Facts newsletter lists several changes, most effective January 1, 2027: Cigna-insured members will require precertification for outpatient non-emergency CT, MRI and PET imaging; manual and power mobility device codes will require prior authorization for Medicare Advantage, Medicare Cost and MSHO members; Actemra is being replaced by the biosimilar Avtozma and several diabetes and insulin drugs are leaving the formulary; and Minnesota Medicaid moves to MNAAC pharmacy reimbursement. The billing team should also note the standing reminder to submit any change to a previously filed claim as a corrected claim with Bill Frequency Code 7.
Harvard Pilgrim Health Care · Effective Jan 1, 2027High impact
Point32Health Medical Necessity Guideline updates
Point32Health is updating Medical Necessity Guidelines across several plan lines. Effective 11/1/2026 (already in effect as of the 2026-11-05 analysis date), prior authorization is removed for Carelon-reviewed noninvasive prenatal testing codes 81420 and 81507 on certain commercial lines, and the 6-month trial and renewal criteria are removed for tonic motor activation. Effective 1/1/2027 (future), prior authorization is added for multiple codes on Tufts Medicare Preferred, Tufts Health Plan SCO, and Tufts Health One Care, and coverage criteria are added for SCODI, vitamin B12 and D testing, and benign skin lesion removal.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Payment discontinued for select procedure codes effective
Effective January 1, 2027, HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid in Virginia) will discontinue reimbursement for 44 specific procedure codes to align with the Virginia Department of Medical Assistance Services (DMAS) fee schedule. The practice must stop billing these codes for dates of service on or after that date, as claims for discontinued codes will be denied or subject to adjustment and recovery.
Anthem BCBS · Effective Jan 1, 2027High impact
[Georgia] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Georgia will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. Practices must review affected patients before the effective date, transition them to covered alternatives where clinically appropriate, and submit prior authorization requests for any nonformulary medications that remain medically necessary.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio will move 10 select medications to nonformulary status, including common drugs for asthma, COPD, diabetes, anticoagulation, and inflammatory conditions. The practice must review patient medication lists, coordinate therapy transitions to covered alternatives before the effective date, and submit pharmacy prior authorizations electronically to avoid claim denials and treatment delays in January.
Anthem BCBS · Effective Jan 1, 2027High impact
[California] 2027 Medicare formulary changes: Prepare now for
Effective January 1, 2027, Anthem Blue Cross Medicare Advantage plans in California will move 10 brand-name medications to nonformulary status, including common drugs for diabetes, asthma, COPD, anticoagulation, and inflammatory conditions. The practice must proactively review Medicare patients on these medications, coordinate transitions to covered alternatives before year-end, and submit prior authorizations electronically to avoid pharmacy claim denials and treatment delays in January.
Sentara Health Plans · Effective Jan 1, 2027High impact
Clinical Policy Updates - Effective January 1, 2026
Effective January 1, 2027, Sentara Health Plans will require prior authorization and/or step therapy precertification for 17 injectable oncology and hematology codes (filgrastim, sargramostim, bevacizumab, pegfilgrastim, rituximab, and trastuzumab products and biosimilars) for Medicare Advantage members in Virginia. The billing team must obtain prior authorization before claims are submitted to avoid denial.
Nebraska Medicaid · Effective Jan 1, 2027High impact
Targeted Case Management Program for Chronic Diseases (TCMP CD) - LB 527
Nebraska Medicaid is implementing a new Targeted Case Management Program for Chronic Diseases (TCMP CD) effective January 1, 2027, paying qualified PCMH-certified providers $75 per member per month for managing beneficiaries with diabetes and chronic kidney disease stage 3 or higher. Providers must enroll as a new PCMH provider type by March 31, 2027, and may submit backdated claims for services provided January 1–March 31, 2027, if filed by October 31, 2027.
Highmark · Effective Jan 1, 2027High impact
ValueBlue Partial Capitation Reimbursement Begins Jan. 1, 2027
Highmark ValueBlue introduces a partial capitation reimbursement model for primary care providers (PCPs) effective January 1, 2027. PCPs must enroll by December 1, 2026, to participate; those who do not enroll will face a 20% reduction in capitated codes on the community fee schedule effective April 1, 2027.
Indiana Medicaid (IHCP) · Effective Jan 1, 2027High impact
BT2026182: COVID-19 vaccine administration to no longer be carved out of managed care
Effective January 1, 2027, COVID-19 vaccine administration services transition from carved-out status to managed care for HIP, Hoosier Healthwise, Hoosier Care Connect, and Indiana PathWays members. Claims for COVID-19 vaccines and administration with service dates on or after 2027-01-01 must be submitted to the member's MCO instead of fee-for-service. FQHCs and RHCs remain carved out and continue submitting to FFS processors.
Mississippi Medicaid (DOM) · Effective Jan 1, 2027High impact
Biomarker Testing Coverage Implemented Effective July 1, 2026
Effective January 1, 2027, 15 specific diabetes supply HCPCS codes will transition from medical/DME billing to exclusive pharmacy billing on Mississippi Medicaid. A transition period runs October 1–December 31, 2026, during which the billing team must update systems to route these codes to pharmacy claims and ensure providers switch members to preferred products on the Diabetic Supply List (DSL). Eight HCPCS codes for insulin pump supplies and adjunctive CGM remain eligible for medical/DME billing and are unaffected.
Anthem BCBS · Effective Jan 1, 2027High impact
[Georgia] Reimbursement policy update: Maternity Services coding changes
Effective January 1, 2027, Anthem Blue Cross and Blue Shield is restructuring maternity services coding for Georgia commercial plans. If CMS does not adopt proposed G-codes, maternity care will shift from global codes to granular reporting using separate antepartum, delivery, and postpartum codes with E/M codes, modifier TH, and frequency limits. The policy is contingent on CMS's decision; Anthem will provide updated guidance if CMS adopts alternative G-codes.
Humana · Effective Jan 1, 2027High impact
SGLT2 Inhibitors (New)
Humana has implemented a new prior authorization policy for SGLT2 Inhibitors effective January 1, 2027, affecting Medicare Advantage members. The policy requires prior auth for six SGLT2 inhibitor medications (Steglatro, Segluromet, Invokana, Invokamet, Invokamet XR, Synjardy, Synjardy XR) and mandates that members have Type 2 diabetes AND have tried or cannot take empagliflozin or dapagliflozin-containing medications before approval.
Humana · Effective Jan 1, 2027High impact
Jardiance (empagliflozin) (New)
Humana Medicare Advantage has implemented a new prior authorization policy for Jardiance (empagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. All three indications require documented failure or inability to use generic dapagliflozin as a prerequisite, with specific exclusions including eGFR <30 for diabetes glycemic control, polycystic kidney disease for CKD, and certain immunosuppressive therapy use for CKD.
Humana · Effective Jan 1, 2027High impact
Januvia (sitagliptin) (New)
Humana has implemented a NEW prior authorization policy for Januvia (sitagliptin) effective January 1, 2027, for Medicare Advantage members with type 2 diabetes. Coverage requires members to have tried or be unable to use generic sitagliptin first, and prior authorization is mandatory for all brand-name Januvia prescriptions.
Humana · Effective Jan 1, 2027High impact
Janumet (sitagliptin and metformin hydrochloride) (New)
Humana Medicare Advantage has implemented a new prior authorization requirement for Janumet (sitagliptin/metformin) effective January 1, 2027. Coverage requires patients to have type 2 diabetes and either tried or be unable to use generic sitagliptin/metformin, with a critical exclusion: patients with a history of pancreatitis are not eligible. This is a brand-to-generic step therapy policy.
Mississippi Medicaid (DOM) · Effective Jan 1, 2027High impact
Diabetic Supply Billing Notice
Mississippi Division of Medicaid will move fifteen diabetes supply HCPCS codes from the medical/DME benefit to exclusive pharmacy billing effective January 1, 2027, so these supplies will need NDC-based pharmacy claims. A transition period runs from October 1 through December 31, 2026, and the change is aimed at letting Medicaid collect manufacturer rebates. Eight other diabetes supply codes remain eligible for medical/DME billing.
UnitedHealthcare · Effective Jan 1, 2027High impact
New AMA issued genetic and molecular prior auth requirements
Effective January 1, 2027, UnitedHealthcare will require prior authorization for five new AMA-issued genetic and molecular testing CPT codes (0672U, 0673U, 0674U, 0675U, 0686U) on commercial and Exchange plans. These codes align with existing genetic testing prior authorization requirements. Claims submitted without prior authorization will be denied and cannot be balance-billed to members.
UnitedHealthcare · Effective Jan 1, 2027High impact
Michigan: The MCT2D CGM prior auth bypass will end on Jan. 1
UnitedHealthcare's prior authorization bypass pilot program for continuous glucose monitors (CGM) in type 2 diabetes patients ends January 1, 2027. After this date, CGM prescriptions will require standard prior authorization and must meet UnitedHealthcare's coverage criteria. Members prescribed CGM on or before December 31, 2026, will retain bypass status for 12 months or until December 31, 2027, whichever comes first.
Humana · Effective Jan 1, 2027High impact
Farxiga (dapagliflozin) (New)
Humana Medicare Advantage has implemented a new prior authorization policy for Farxiga (dapagliflozin) effective January 1, 2027, covering three indications: Type 2 Diabetes Mellitus, Heart Failure, and Chronic Kidney Disease at Risk of Progression. The policy requires prior authorization for brand Farxiga when generic dapagliflozin has not been tried or cannot be used, with specific clinical criteria and exclusions for each indication.
Humana · Effective Jan 1, 2027High impact
DPP-IV, SGLT2 Combination Products (New)
Humana Medicare Advantage has implemented a new prior authorization policy for DPP-IV/SGLT2 combination diabetes medications (Steglujan, Qtern, Glyxambi, dapagliflozin-saxagliptin). Effective January 1, 2027, all claims for these products require prior authorization and must meet two criteria: Type 2 Diabetes Mellitus diagnosis AND documented trial or contraindication to a single DPP-4 inhibitor (sitagliptin or linagliptin) OR a single SGLT2 inhibitor (empagliflozin or dapagliflozin). Approvals are granted for plan year durations or as determined through clinical review.
BCBS Illinois · Effective Jan 1, 2027High impact
Pharmacy Program Updates: Prior Authorization Changes Effective Jan. 1, 2027
Effective January 1, 2027, Blue Cross Blue Shield of Illinois (administered through Prime Therapeutics) is updating prior authorization criteria for 16 pharmacy programs covering specialty medications across multiple therapeutic categories including biologics, immunomodulators, oncology agents, and rare disease treatments. Two new prior authorization programs are also being introduced (Hepatitis D and Nereus). All changes affect multiple plan types across Illinois and require billing teams to implement updated PA requirements in their systems.
Ambetter · Effective Jan 1, 2027High impact
Upcoming Changes to Pharmacy Policies (PDF)
This pharmacy policy update effective 1/1/2027 makes extensive changes to medication coverage criteria across 25+ drugs, including preferred agent redirections (e.g., Stelara to Imuldosa for autoimmune conditions), updated GLP-1 step-through requirements, addition of new line-of-business coverage (HIM/ICHRA), and retirement of obsolete policies. The most clinically impactful changes affect GLP-1 receptor agonists, insulin products, DMARDs, and biologics used in endocrinology, rheumatology, oncology, and dermatology practices.
Medicare/CMS · Effective Jan 1, 2027High impact
2026-09-17 - Mandatory Ambulatory Specialty Model Final Participants
CMS has released the final participant list for the mandatory Ambulatory Specialty Model (ASM) effective for the 2027 performance year. Specialists treating Medicare patients for low back pain or heart failure in outpatient settings who are selected must comply with all model requirements, including reporting required measures and attestations. Medicare Part B payments will be adjusted based on reported performance metrics.

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[New York] Clinical Criteria updates

[Virginia] Clinical Criteria updates

MA12.010e, Remote Physiologic Monitoring and Remote Therapeutic Monitoring

HealthPro News – October 2026

Cardiovascular Disease Risk Tests (for New Mexico Only)

Cardiovascular Disease Risk Tests (for New Jersey Only)

Cardiovascular Disease Risk Tests (for Kentucky Only)

Breast Imaging for Screening and Diagnosing Cancer (for Kentucky Only)

Laboratory Payment Policies: Dec. 1, 2026 updates

AB2026-10-002 Medicare only

[Ohio] Avalon Policy Updates

Provider Notification - New Policy Updates - Clinical Payment, Coding, and Policy Changes Effective December 1, 2026

Leuprolide Acetate Depot Suspension [Lupron Depot (1 month) 7.5mg, Lupron Depot (3 month) 22.5mg, Lupron Depot (4-Month) 30 mg, Lupron Depot (6-Month) 45 mg]; Leuprolide acetate depot (3-month 22.5 mg); Lutrate Depot® (3-month 22.5 mg)

[New York] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Ohio] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

[Virginia] Specialty pharmacy updates

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

[Georgia] Reimbursement policy update: Facility Guidelines for Claims Related to Professional Services — Facility

Preventive Care Reminder Sent to Members

December 2026 Drug List Change Notification (Commercial)

FQHC and RHC Policy for UIS Members Transitioning to Fee-for-Service on January 1, 2027

Denosumab

Denosumab

Denosumab

Denosumab

Omnibus Codes

Fast Facts Newsletter - November 2026

Point32Health Medical Necessity Guideline updates

[Virginia] Payment discontinued for select procedure codes effective

[Georgia] 2027 Medicare formulary changes: Prepare now for

[Ohio] 2027 Medicare formulary changes: Prepare now for

[California] 2027 Medicare formulary changes: Prepare now for

Clinical Policy Updates - Effective January 1, 2026

Targeted Case Management Program for Chronic Diseases (TCMP CD) - LB 527

ValueBlue Partial Capitation Reimbursement Begins Jan. 1, 2027

BT2026182: COVID-19 vaccine administration to no longer be carved out of managed care

Biomarker Testing Coverage Implemented Effective July 1, 2026

[Georgia] Reimbursement policy update: Maternity Services coding changes

SGLT2 Inhibitors (New)

Jardiance (empagliflozin) (New)

Januvia (sitagliptin) (New)

Janumet (sitagliptin and metformin hydrochloride) (New)

Diabetic Supply Billing Notice

New AMA issued genetic and molecular prior auth requirements

Michigan: The MCT2D CGM prior auth bypass will end on Jan. 1

Farxiga (dapagliflozin) (New)

DPP-IV, SGLT2 Combination Products (New)

Pharmacy Program Updates: Prior Authorization Changes Effective Jan. 1, 2027

Upcoming Changes to Pharmacy Policies (PDF)

2026-09-17 - Mandatory Ambulatory Specialty Model Final Participants