What insurance policy changes affect Pharmacy providers?

Pharmacy 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 Pharmacy?

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

How do I get notified of new Pharmacy policy changes?

Sign up for a free PolicyChanges.app account and create a saved search filtered to Pharmacy. 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 Pharmacy?

Based on tracked changes, Pharmacy updates have come from payers including Blue Cross Blue Shield of North Dakota, Health Net, UnitedHealthcare.

PAYER POLICY CHANGES

Pharmacy Insurance Policy Changes

Keeping up with insurance policy changes that affect Pharmacy 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 Pharmacy providers and their billing teams can act before deadlines pass.

Blue Cross Blue Shield of North Dakota · Effective Nov 10, 2026High impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota has revised its commercial prior authorization medical drug policies for drugs including Avlayah, bendamustine, bevacizumab, denosumab, omalizumab, Pluvicto and Sarclisa, with revisions effective November 10, 2026. Several HCPCS changes are effective October 1, 2026, including HCPCS codes J1757, J9066 and Q5173, and J3590 is discontinued for Avlayah, Ponlimsi and denosumab-adet on that date. The updates also add the number of days allowed to the Length of Authorization sections, replace specific contraindications in Universal Criteria with general FDA contraindication language, and add ICD-10 codes including C83.36 and C50.A0 through C50.A2.
Health Net · Effective Nov 17, 2026High impact
26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net California has updated the Injectable Medication HCPCS/DOFR (Division of Financial Responsibility) Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes with 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1061) to ensure accurate claims processing and proper financial responsibility assignments for injectable medications.
Health Net · Effective Nov 17, 2026High impact
26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net/Community Health Plan of Imperial Valley updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes, plus 3 DOFR categorization corrections. Billing teams must obtain and implement the complete crosswalk update (26-1062) to ensure accurate coding and financial responsibility assignment for all injectable medication claims.
Health Net · Effective Nov 17, 2026High impact
26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk
Health Net's Pharmacy Advisory Committee has updated the Injectable Medication HCPCS/DOFR Crosswalk effective November 17, 2026, adding 11 new injectable medications, 15 new biosimilars, 6 new generic medications, and making 27 updates to existing codes. The update includes 3 DOFR categorization corrections, 2 administrative changes, and 21 code description updates that will affect how injectable medications are billed and assigned to financial responsibility categories under the Health Net Provider Participation Agreement.
UnitedHealthcare · Effective Dec 1, 2026High impact
Erythropoiesis-Stimulating Agents
UnitedHealthcare Community Plan of Indiana revised its Medicaid Erythropoiesis-Stimulating Agents medical benefit drug policy, effective 2026-12-01. Coverage criteria now use "ESAs" as the umbrella term for all listed agents, treat each hematocrit value as either pretreatment (first 4-6 weeks) or on-treatment monitoring, and use a hemoglobin-to-hematocrit conversion factor of 3 when only hemoglobin is measured. The policy also removes language stating it does not apply to Indiana.
Capital Blue Cross · Effective Dec 1, 2026High impact
AB2026-11-005 Medical policies
Capital Blue Cross administrative bulletin 2026-11-005, dated November 1, 2026, lists medical policy updates with an effective date of December 1, 2026 unless otherwise indicated. Changes effective December 1, 2026 include added procedure codes in the Durable Medical Equipment policy and new preauthorization requirements for several Prime Therapeutics injectables. Many other changes take effect January 1, 2027, including EviCore's Clinical Guidelines for Lab Management Program, Version 1.0.2027, updated Evolent radiology and radiation oncology guidelines, and updated TurningPoint musculoskeletal and cardiology policies.
Iowa Medicaid · Effective Dec 1, 2026High impact
IL 2742-MC-FFS: Pharmacy Benefit Carve-Out
Effective December 1, 2026, Iowa Medicaid is transitioning outpatient pharmacy benefits for managed care members from MCO administration to fee-for-service administration through Optum Rx. All outpatient pharmacy claims with dates of service on or after December 1, 2026, must be submitted using new point-of-sale information (BIN: 011933, PCN: IAPOP) and will be processed by Optum Rx instead of MCOs. Prior authorizations will also be administered by Optum Rx beginning December 1, 2026.
SC Medicaid - SCDHHS · Effective Dec 1, 2026High impact
Medicaid Ordering, Referring and Prescribing Providers: Pharmacy Update
South Carolina Medicaid is implementing a hard enforcement of ORP (Ordering, Referring, and Prescribing) provider enrollment requirements for pharmacy claims effective December 1, 2026. Starting that date, pharmacy claims submitted without the prescriber's National Provider Identifier (NPI) will be rejected and not paid. Pharmacies can request one-time claim rejection overrides by contacting the fee-for-service pharmacy technical help desk.
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.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield is implementing new prior authorization and quantity limit requirements for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty medications. Billing teams must begin requesting prior authorization for affected medications on or after the effective date, and include NDC codes on claims to expedite processing. Previously covered patients may lose coverage if prior authorization is not obtained.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements and quantity limits for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for eleven additional specialty medications. Billing teams must begin requesting prior authorization for these drugs on or after the effective date, and include NDC codes on claims to expedite processing.
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
[Georgia] Specialty pharmacy updates
Anthem Blue Cross Blue Shield Georgia is implementing new prior authorization and quantity limit requirements for 5 specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty drugs. Billing teams must request prior authorization for affected medications and include NDC codes on claims to expedite processing; previously covered patients may require new authorization for continued medication use.
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.
Blue Cross Blue Shield of Nebraska · Effective Dec 15, 2026High impact
Medical/Pharmacy Policy Updates Effective 12/15/2026
Blue Cross and Blue Shield of Nebraska (BCBSNE) is implementing a new medical policy (MPC X.242 OptimizeRX) effective 12/15/2026 that establishes step therapy requirements for multiple biologic medications. Preauthorization is now required for all nonpreferred products, and patients must demonstrate contraindication, intolerance, or failure to a preferred product before nonpreferred alternatives will be considered. This applies to both new and established patients across denosumab, infliximab, rituximab, tocilizumab, and trastuzumab drug classes.
Blue Cross Blue Shield of Nebraska · Effective Dec 15, 2026High impact
Medical/Pharmacy Policy Updates Effective 12/15/2026
Blue Cross and Blue Shield of Nebraska (BCBSNE) has implemented a new step therapy requirement for six biologic drug classes effective 12/15/2026. Patients on non-preferred products (biosimilars and brand-name biologics) now require prior authorization and documented evidence of contraindication, intolerance, or failure to a preferred product before coverage. This affects denosumab, infliximab, rituximab, tocilizumab, and trastuzumab products across all patient populations.
Harvard Pilgrim Health Care · Effective Dec 31, 2026High impact
Reauthorization requirements for targeted Immunomodulators
Point32Health has implemented phased reauthorization requirements for targeted immunomodulator medications used for dermatological indications (hidradenitis suppurativa, plaque psoriasis, psoriatic arthritis) across Harvard Pilgrim Health Care Commercial and Tufts Health Direct. Existing prior authorizations were terminated on June 30, 2026 for members using these drugs for over one year; additional authorizations will terminate on December 31, 2026 for members reaching one year of use by January 1, 2027, requiring new prior authorization requests submitted beginning January 1, 2027 under updated reauthorization criteria.
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
[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
[New York] 2027 Medicare formulary changes: Prepare now for
Beginning January 1, 2027, Anthem Medicare Advantage formulary changes will move 10 select medications to nonformulary status in New York. The practice should review Medicare patients taking these drugs (Anoro Ellipta, Brilinta, Janumet, Januvia, Jentadueto, Opsumit, Spiriva Handihaler/Respimat, Stelara, Xeljanz XR, Xigduo XR) and transition them to covered alternatives before the effective date to prevent pharmacy claim rejections and treatment delays.
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.
Capital Blue Cross · Effective Jan 1, 2027High impact
AB2026-11-003 Pharmacy updates
Capital Blue Cross administrative bulletin 2026-11-003, dated November 1, 2026, updates its Advantage and Value Plus, CHIP, Elite and Exclusive, and Value formularies and pharmacy utilization management programs, with an effective date of January 1, 2027 unless otherwise indicated. The changes include an expanded list of drugs requiring prior authorization, new and modified quantity level limits, new and modified step therapy requirements, and drugs removed from formulary. A footnote states that one change is effective October 1, 2026, and that existing users will have a PA to grandfather them until 10/1.
Blue Cross Blue Shield of Vermont · Effective Jan 1, 2027High impact
Pharmacy Updates
Effective January 1, 2027, NPF (likely a Blue Cross Vermont plan) is implementing significant pharmacy formulary changes including uptiers of three medications, addition of step therapy for Gemtesa, exclusion of 40+ brand-name drugs with generic/alternative options available, removal of Viread from the Healthcare Reform List (subject to deductible/cost-share), and new quantity limits on diabetic test strips, Omnipod, bowel prep kits, and Twist refill kits. Billing teams must update coverage rules, prior authorization workflows, and claims processing to reflect these exclusions and new quantity limits.
Blue Cross Blue Shield of Rhode Island · Effective Jan 1, 2027High impact
Payment policy updates
BCBS Rhode Island issued multiple payment policy updates with staggered effective dates: pharmacy MPS lists updated (October 1, 2026—already effective), CPT 87494 (STI testing) added to preventive benefits (January 1, 2026—already effective), fee-based PCP attribution policy updated per state regulation (September 21, 2026 bulletin), and maternity/OB services billing fundamentally restructured from bundled to unbundled codes effective January 1, 2027. The OB policy change requires providers to bill individual E&M and delivery codes instead of global OB packages starting 2027.
Blue Cross Blue Shield of Nebraska · Effective Jan 1, 2027High impact
OptimizeRx Medical Policy Update Effective 01/01/2027
Blue Cross and Blue Shield of Nebraska (BCBSNE) is implementing a new step therapy requirement for Medical Policy X.242 OptimizeRX effective January 1, 2027. All preferred and non-preferred products will now require documented evidence of contraindication, intolerance, or inadequate response to a preferred product before coverage of a nonpreferred product is approved. This step therapy applies to both treatment-naïve and established patients, and preauthorization is required.
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.
Aetna · Effective Jan 1, 2027High impact
OfficeLink Updates - November 2026 notices and reminders (PDF)
Aetna's November 2026 OfficeLink newsletter, issued 2026-11-01, covers several changes with different dates. The biggest is a restructuring of maternity care coding, with global maternity codes retired and replaced by service-based codes effective January 1, 2027, plus a transition period for prenatal preventive visits that began September 1, 2026. It also adds precertification for several specialty drugs on staggered dates from November 1, 2026 through February 1, 2027, and notes a Medicare MolDX molecular testing Z-code requirement that has no stated date and an observation reminder that is already in effect.
Humana · Effective Jan 1, 2027High impact
Benzodiazepine Limited Days Supply (New)
Effective January 1, 2027, Humana Illinois Medicaid implements a new pharmacy coverage policy limiting initial benzodiazepine dispensing to a maximum 14-day supply for new users (no benzodiazepine claim in past 60 days), with prior authorization required for initial claims exceeding this limit. Subsequent fills after the initial dispensing follow standard renewal guidelines. This policy applies to 15 benzodiazepine medications across all formulations.
Ambetter · Effective Jan 1, 2027High impact
Effective January 1, 2027: Pharmacy and Biopharmacy Policies
Effective January 1, 2027, Superior HealthPlan and Ambetter plans are implementing comprehensive updates to 30+ pharmacy and biopharmacy policies, including new prior authorization criteria, preferred drug redirections, and line-of-business expansions across multiple medication classes (insulin, GLP-1 agonists, DMARDs, biologics, and others). Billing teams must verify which policies affect their patient population and update prior authorization workflows, formulary redirects, and claim processing rules to reflect the new medical necessity criteria and preferred agent requirements.
Anthem BCBS · Effective Jan 1, 2027High impact
[New York] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (New York) is expanding its specialty pharmacy precertification requirements for Medicare Advantage plans. Effective January 1, 2027, step therapy will be added to the precertification review process for 10 Part B medications (denosumab, bendamustine, and pemetrexed formulations). Additionally, effective February 1, 2027, three new Part B drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will be included in the precertification review process. Noncompliance with these requirements may result in claim denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective February 1, 2027, three new Part B drugs (golimumab, bevacizumab, and isatuximab) will require prior authorization. Additionally, effective January 1, 2027, step therapy requirements are being added to eight existing Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate formulations). Noncompliance with precertification requirements may result in claim denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective January 1, 2027, step therapy precertification will apply to multiple Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate products). Additionally, effective February 1, 2027, three new specialty drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will require precertification review. Noncompliance with these new requirements may result in claim denial.
MassHealth · Effective Jan 1, 2027High impact
All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected
Effective January 1, 2027, MassHealth will require all ordering, referring, prescribing, attending, supervising, and operating (ORPASO) providers on claims to be enrolled with MassHealth on the date of service (or within 90 days after first date of service for ordered/referred/prescribed services). Claims with unenrolled providers in these roles will be denied. MassHealth is currently sending informational denial messages to prepare providers for this enforcement.
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.
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.
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.
Blue Cross Blue Shield of Vermont · Effective Jan 1, 2027High impact
Pharmacy Updates
Effective January 1, 2027, this NPF formulary update removes 60+ brand-name drugs from coverage, uptiers 3 medications to require generic alternatives, adds step therapy to Gemtesa, implements quantity limits on diabetic test strips/insulin pumps, and removes Viread from the Health Care Reform List. Billing teams must immediately identify affected patients, update prior authorization workflows, and prepare claims adjustments for the January 1 effective date.
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.
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.
Blue Cross and Blue Shield of Kansas City · Effective Jan 1, 2027High impact
BlueSpeak September 2026: Drug Waste Policy Edit Effective January 1, 2027
Effective January 1, 2027, Blue KC is enforcing stricter single-dose vial (SDV) drug waste billing requirements under policy POL-PP-234. Providers must now use modifiers JW (for waste) and JZ (for zero waste) correctly, minimize waste by selecting appropriate vial sizes, document waste details in medical records, and report wasted drug amounts on separate claim lines. Non-compliance will result in claim denials and potential overpayment recoupment.
Mississippi Medicaid (DOM) · Effective Jan 1, 2027High impact
Pharmacy Point-of-Sale Drugs: Prior Authorization Requirements
Effective January 1, 2027, Mississippi Medicaid is transitioning all pharmacy prior authorization submissions to mandatory electronic submission through the MESA Provider Portal, replacing paper and phone submission methods. Providers must register for portal access and train staff immediately to avoid claim denials starting in the new year.
Anthem BCBS · Effective Jan 1, 2027High impact
[New York] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield in New York is implementing new prior authorization requirements for three specialty oncology medications (Avgemsi, Docivyx, Beizray) effective January 1, 2027. Additionally, step therapy requirements are being applied to pemetrexed, bendamustine, and docetaxel products, with specific formulations designated as preferred or non-preferred, requiring step therapy protocols before dispensing non-preferred agents.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield Ohio is implementing new prior authorization requirements and step therapy protocols for specialty pharmacy oncology medications effective January 1, 2027. Starting that date, providers must request prior authorization for Avgemsi (gemcitabine), Docivyx (docetaxel), and Beizray (docetaxel) before dispensing, and must follow step therapy requirements for pemetrexed, bendamustine, and docetaxel products, with preferred and non-preferred formulations designated.
Highmark · Effective Jan 1, 2027High impact
Medical Injectable Drug Program Changes in the New Year
Effective January 1, 2027, Highmark is adding 13 new drugs to its Medical Injectable Drug Program and adjusting reimbursement rates to align with average selling price (ASP) or average wholesale price (AWP) for drugs without an ASP. Billing teams must update their systems to recognize the new HCPCS codes and apply the corrected reimbursement methodology for these injectable medications.
Utah Medicaid · Effective Jan 1, 2027High impact
September 2026 Medicaid Information Bulletin
Utah Medicaid's September 2026 bulletin includes several billing changes that begin January 1, 2027, including telehealth modifiers 93 or 95, service-level reporting for maternity care, per diem billing for residential, partial hospitalization and intensive outpatient behavioral health programs, and single-unit billing for several psychotherapy and evaluation codes. Other items already took effect, including the Spravato observation codes and the home health TE modifier change on July 1, 2026, and the nursing facility ancillary changes, which apply retroactively to services on or after July 1, 2026. Unless otherwise noted in the bulletin, changes take effect on September 1, 2026.
Blue Cross and Blue Shield of Kansas City · Effective Jan 1, 2027High impact
BlueSpeak Provider Newsletter — July 2026
Blue KC is changing its maternity billing for all lines of business to align with AMA coding changes that eliminate traditional global maternity billing codes effective January 1, 2027, so providers will submit claims throughout the pregnancy instead of one global claim at delivery. Other updates include prior authorization additions for Commercial and ACA plans effective September 1, 2026, a hemodialysis URR modifier requirement effective July 1, 2026, and a post-payment review partnership with Cotiviti beginning October 1, 2026.
Security Health Plan · Effective Jan 1, 2027High impact
Provider News - July 2026
Security Health Plan discontinues its SSI Medicaid product effective Jan. 1, 2027, and members will need to transition to a new health plan for 2027; BadgerCare Plus is not affected. Maternity care billing moves from global maternity care codes to an itemized billing structure effective Jan. 1, 2027. Pharmacy benefit prior authorization requests can be submitted online through CoverMyMeds.com effective July 1, 2026, and provider questions about coordination of benefits go to (800) 548-1224 effective March 1, 2026.

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Pharmacy Policies Available Online

26-1061sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1062sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

26-1060sum Summary Update: 3rd Quarter 2026 Injectable Medication HCPCS/DOFR Crosswalk

Erythropoiesis-Stimulating Agents

AB2026-11-005 Medical policies

IL 2742-MC-FFS: Pharmacy Benefit Carve-Out

Medicaid Ordering, Referring and Prescribing Providers: Pharmacy Update

AB2026-10-002 Medicare only

[New York] Specialty pharmacy updates

[Ohio] Specialty pharmacy updates

[Virginia] Specialty pharmacy updates

[Georgia] Specialty pharmacy updates

Preventive Care Reminder Sent to Members

Medical/Pharmacy Policy Updates Effective 12/15/2026

Medical/Pharmacy Policy Updates Effective 12/15/2026

Reauthorization requirements for targeted Immunomodulators

Fast Facts Newsletter - November 2026

Point32Health Medical Necessity Guideline updates

[Georgia] 2027 Medicare formulary changes: Prepare now for

[Ohio] 2027 Medicare formulary changes: Prepare now for

[New York] 2027 Medicare formulary changes: Prepare now for

[California] 2027 Medicare formulary changes: Prepare now for

AB2026-11-003 Pharmacy updates

Pharmacy Updates

Payment policy updates

OptimizeRx Medical Policy Update Effective 01/01/2027

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

OfficeLink Updates - November 2026 notices and reminders (PDF)

Benzodiazepine Limited Days Supply (New)

Effective January 1, 2027: Pharmacy and Biopharmacy Policies

[New York] Specialty pharmacy precertification list expands

[Ohio] Specialty pharmacy precertification list expands

[Virginia] Specialty pharmacy precertification list expands

All Provider Bulletin 421: Enrollment Requirement for All Providers on Claims Submitted to MassHealth - Corrected

Biomarker Testing Coverage Implemented Effective July 1, 2026

SGLT2 Inhibitors (New)

Diabetic Supply Billing Notice

Pharmacy Updates

Farxiga (dapagliflozin) (New)

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

Upcoming Changes to Pharmacy Policies (PDF)

BlueSpeak September 2026: Drug Waste Policy Edit Effective January 1, 2027

Pharmacy Point-of-Sale Drugs: Prior Authorization Requirements

[New York] Specialty pharmacy updates

[Ohio] Specialty pharmacy updates

Medical Injectable Drug Program Changes in the New Year

September 2026 Medicaid Information Bulletin

BlueSpeak Provider Newsletter — July 2026

Provider News - July 2026