PAYER POLICY CHANGES

Oklahoma Medicaid Policy Changes

Policy changes from Oklahoma SoonerCare and from Medicaid managed care plans in Oklahoma, with the Medicaid prior authorization lists and payer contacts we track for the state. Each item links to its public source.

Humana · Effective Nov 5, 2026Medium impact
Foot Bath Medications (New)
Humana's new Medicaid pharmacy guidance (effective November 5, 2026) states that select medications such as budesonide, ciclopirox, clindamycin, fluocinonide, ketoconazole, linezolid, nystatin, and vancomycin, when dispensed for mixing into foot baths or soaks, are generally not medically necessary and may lack compendia or label support. Claims for these drugs submitted close together with other foot bath medication claims may reject with NCPDP error code 88 / internal code 527 ('Questionable compendia support'), and medications are approved only if label or compendia-supported use is shown on clinical review.
Humana · Identified Nov 1, 2026Low impact
Humana Physician News: Q1 2026
This is a Q1 2026 informational newsletter from Humana announcing new provider resources, updated clinical initiatives, and published claims payment policies. Key items include a new Provider Marketing Resource Center, DME network referral guidance, kidney disease screening focus, bladder health initiatives, value-based care resources, required 2026 training reminders, new Medicaid prior authorization lists for three states, and revised claims payment policies. Most content is promotional or educational; specific billing workflow changes are limited to Medicaid provider-administered medication prior authorization requirements for Indiana, Louisiana, and Oklahoma.
Humana · Effective Jul 1, 2026High impact
Humana Physician News: Q2 2026
This Q2 2026 Humana newsletter (published April 1, 2026, discovered November 1, 2026) contains multiple effective dates spanning past, ongoing, and future actions. Key changes include: (1) New prior authorization lists effective July 1, 2026, for Medicare Advantage, Dual Eligible SNPs, and Medicaid plans; (2) Medicaid provider-administered medication PAL changes for seven states; (3) PPO members inactive since May 1, 2024, were automatically unpaneled as of March 1, 2026; (4) New claims-based attribution rules for MA products effective April 1, 2026; and (5) Published claims payment policies including a new Paper Claim Administrative Fee. The newsletter emphasizes timely prior authorization submission before services are fully furnished to avoid claim denial and retroactive authorization processing.
Humana · Effective Jan 1, 2026Medium impact
Humana Physician News: Q3 2026
This Q3 2026 Humana newsletter (published July 1, 2026, discovered November 1, 2026) is historical material containing mixed-date guidance. Key items: (1) Clinical documentation for Medicare prior authorizations must be submitted at time of request to meet CMS's 7-day decision requirement—already effective January 1, 2026. (2) Enhanced real-time PA workflow for diagnostic imaging in GA, NC, SC, VA now available. (3) Medicaid medication list updates for five states. (4) New and revised claims payment policies published. (5) Informational resources on safe prescribing, obesity management, and care gap closure. Most actionable items are already in effect or operational.
Humana · Effective Oct 19, 2016Medium impact
Clinical Trials Policy (Revised)
This is historical material: a Humana Clinical Trials Pharmacy Policy originally effective 2016-10-19, newly discovered 2026-10-28. The policy governs coverage of routine care and services costs for members enrolled in federally funded or approved clinical trials for cancer or other life-threatening illnesses, with specific eligibility criteria, exclusions, and requirements for trial approval. The revision date of 2026-10-28 reflects recent policy updates; verify current applicability with Humana's online policy portal before applying.
Humana · Effective Jan 1, 2019Medium impact
Antipsychotic Utilization Program (Revised)
This is a historical policy document (originally effective 2019-01-01, revised 2026-10-28) that establishes prior authorization requirements for atypical and typical antipsychotic medications when prescribed to members with dementia without appropriate clinical indication. The policy applies to Medicare and multiple state Medicaid programs (FL, IL, SC, IN, OK, VA) and outlines clinical approval criteria based on age, compendia-supported diagnoses, and behavioral severity. The billing team should verify current applicability through Humana's online policy portal rather than relying on this printed version.
Oklahoma SoonerCare · Identified Oct 28, 2026Medium impact
Provider Letter 2026-20: Re: Transitions of Care Guidance
OHCA issued transitions of care guidance for Medicaid members moving between SoonerSelect managed care and SoonerCare fee-for-service. The policy establishes three scenarios with different prior authorization and medical necessity determination requirements: members transitioning from SoonerSelect to SoonerCare will have previously authorized services honored for up to 90 days; members with active 90-day transition PAs who move to SoonerCare in that same period will have services honored for up to 30 days; and unique eligibility changes will be reviewed case-by-case. Providers must submit SoonerSelect CE approval letters when requesting continuance of previously authorized services.
Oklahoma SoonerCare · Identified Oct 24, 2026Low impact
Provider Letter 2026-19: Re: Provider Contracting Returned to Normal Processing Times
Oklahoma Health Care Authority (OHCA) has resolved provider contracting backlogs and returned to normal processing times. The agency has implemented new data-sharing workflows with SoonerSelect plans and established a process for claims affected by delayed contract placement; providers should reference Provider Letter 2026-18 for instructions on handling impacted claims.
Humana · Effective Jan 1, 2020Medium impact
Previous Treatment/Prior Therapy/Trial (Revised)
This is historical guidance (originally effective 2020-01-01, most recently revised 2026-10-21) defining how Humana interprets 'Previous Treatment,' 'Trial,' and 'Prior Therapy' requirements in pharmacy coverage policies across Medicare and multiple state Medicaid programs. The policy clarifies that a single pharmacy claim (typically 28–30 days, or less for certain therapeutic classes) may satisfy prerequisite therapy documentation, unless a shorter timeframe is specified in drug-specific clinical policies. Members in their first 90 days of coverage are exempt from prerequisite therapy review. Billing teams should verify current applicability before applying this guidance to coverage determinations.
Humana · Effective Apr 1, 2024High impact
Opioid Utilization Program - Morphine Milligram Equivalent (MME) edits (Revised)
This is a historical Medicaid policy document for Oklahoma (effective April 1, 2024, revised November 17, 2025) establishing morphine milligram equivalent (MME) quantity limits and prior authorization requirements for opioid medications. Daily cumulative MME doses exceeding 90 mg require clinical review and prior authorization, with exceptions for cancer, sickle-cell disease, hemophilia, palliative care, and long-term care residents. The policy was newly discovered on October 23, 2026, but is already in effect; billing teams should verify current applicability with Humana rather than treating this as a new requirement.
Humana · Effective Aug 28, 2010Medium impact
Drug Utilization Management and Clinical Edits Tools (Revised)
This is a historical pharmacy policy document from August 28, 2010, newly discovered on October 21, 2026. The policy establishes Humana's Drug Utilization Management (DUM) and clinical edits framework, including step therapy, quantity limits, prior authorization, accumulation edits, and duplication edits across Medicare and multiple state Medicaid programs. The document was revised on October 21, 2026, but no specific content changes from the original effective date are detailed in this version.
Humana · Effective Jan 1, 2017Low impact
Quantity Limitation (Revised)
This is a historical policy document from January 1, 2017 that was recently discovered (October 21, 2026). It establishes Humana's framework for pharmacy quantity limitations across Medicare and multiple state Medicaid programs. The policy permits quantity limits based on FDA-approved dosing, medical literature, and treatment guidelines, with exceptions available for dosage titration, compendia-supported dosages, failed trials, or individual member characteristics. The most recent revision is October 21, 2026, but no new effective date or changes are stated in this revision—verify current applicability with Humana's online policy portal.
Humana · Effective Jun 3, 2020Low impact
Non-FDA Approved Medications (Revised)
This is historical material from a Humana Medicaid pharmacy policy originally effective June 3, 2020, revised October 21, 2026. The policy establishes that non-FDA approved medications are excluded from Humana formularies unless reviewed and approved by the Pharmacy and Therapeutics (P&T) Committee. Coverage for approved non-FDA medications is limited to the plan year duration. No new actionable changes are indicated; verify current applicability with Humana before applying this guidance.
Oklahoma SoonerCare · Identified Oct 10, 2026Medium impact
Provider Letter 2026-18: Re: OHCA Contracting Delays: Claims Resubmission Exception Form Available
OHCA (Oklahoma Health Care Authority) has established an exception process for SoonerCare and SoonerSelect claims affected by provider contracting delays. Providers with denied or unsubmitted claims due to delayed enrollment must complete a form, wait 15 business days, then resubmit claims. All requests must be submitted by January 31, 2027. This is a temporary administrative workflow to address a specific backlog situation.
Humana · Effective Jul 29, 2026Medium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)
Humana Oklahoma Medicaid has released a new policy (effective 07/29/2026) establishing coverage criteria for Fractional Flow Reserve with Computed Tomography (FFRCT). The policy covers CPT 75580 only for specific clinical scenarios: intermediate-risk CAD patients with acute/stable chest pain and CCTA-confirmed stenosis of 40-90%, or stable nonobstructive CAD patients with persistent symptoms despite optimal medical therapy. Multiple exclusions apply, including recent MI, acute coronary syndrome suspicion, and stenosis >90%.
UnitedHealthcare · Effective Jan 1, 2027High impact
New oncology prior authorization code updates
Effective January 1, 2027, UnitedHealthcare is adding prior authorization requirements for 11 HCPCS oncology medication codes when administered in outpatient settings for cancer treatment. These codes include busulfan, leucovorin calcium, luspatercept, dexrazoxane, dinutuximab, octreotide, triptorelin, omidubicel, zoledronic acid, and cyclosporine. This change applies across commercial, Medicare Advantage, Medicaid, and Individual Exchange plans.
BCBS Oklahoma · Effective Jan 1, 2027High impact
New Digital Interfaces To Simplify Prior Authorization Requests
Effective January 1, 2027, this Blue Cross Blue Shield plan will launch new application programming interfaces (APIs) to streamline prior authorization requests and provide real-time access to patient data, encounter information, and claims data through your EHR system. This CMS-required update applies to Medicare Advantage, Medicaid, and select commercial members, reducing administrative burden and enabling faster treatment decisions.
Humana · Effective Jan 1, 2020Medium impact
Previous Treatment/Prior Therapy/Trial (Revised)
This is a guidance policy clarifying how Humana defines and accepts 'Previous Treatment,' 'Trial,' and 'Prior Therapy' for pharmacy prerequisite therapy requirements across Medicare and multiple Medicaid state plans (FL, SC, IN, OK, VA). The policy was revised on September 23, 2026, and establishes that a single pharmacy claim (typically 28-30 days, or less for certain drug classes like antibiotics) or documented prescriber statement of medication failure can satisfy these prerequisites, with consideration for the member's entire treatment history unless a specific timeframe is defined in the underlying clinical coverage policy.
Oklahoma SoonerCare · Effective Jul 1, 2026High impact
Provider Letter 2026-17: Rates Calculation Correction and Claims Recycling
OHCA identified and corrected a fee schedule calculation error that was implemented July 1, 2026. The Oklahoma Health Care Authority is retroactively adjusting all impacted Title XIX (Medicaid) fee-for-service claims over multiple weeks, with adjustments visible on weekly remittance advice starting September 30, 2026. This correction aligns rates with current CMS fee schedules and is not a methodology change.
Humana · Identified Sep 22, 2026High impact
Drug Utilization Management and Clinical Edits Tools (Revised)
This is a guidance policy update (revised September 23, 2026) that clarifies Humana's Drug Utilization Management (DUM) and clinical edits tools across pharmacy claims. The policy outlines nine categories of electronic clinical edits (accumulation, drug/age, drug/disease, drug/drug, drug/pregnancy, duplication, prior authorization, quantity limits, and step therapy) that will be applied at point-of-service to ensure safe, cost-effective medication therapy. Four drug classes receive grandfathering protections: antidepressants, antipsychotics, anticonvulsants (for epilepsy), antineoplastics, antiretrovirals, and immunosuppressants (transplant prophylaxis).
Humana · Effective Jan 1, 2022High impact
Anticholinergic Polypharmacy Agents (Revised)
Humana implemented a safety edit for anticholinergic polypharmacy (concurrent use of 2+ anticholinergic medications) in members age 65+. Approval now requires provider attestation that benefits outweigh risks of falls, fractures, cognitive decline, and delirium per AGS Beers Criteria 2023. Members in hospice are exempt from this requirement. This guidance applies across Medicare and multiple state Medicaid programs.
Oklahoma SoonerCare · Identified Sep 18, 2026High impact
Provider Letter 2026-16: Re: Billing of Peer Recovery Support Services (H2015)
Effective immediately, providers billing for Peer Recovery Support Services (HCPCS code H2015) through SoonerCare (Oklahoma Medicaid) must have a current contract with the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS). SoonerCare enrollment and ODMHSAS certification alone do not satisfy this requirement. Providers billing H2015 without the required ODMHSAS contract risk claim recoupment, audit findings, and compliance actions.
Humana · Effective Sep 16, 2026High impact
Applied Behavior Analysis - MEDICAID - OKLAHOMA (New)
Humana has released a new Applied Behavior Analysis (ABA) coverage policy for Oklahoma Medicaid effective 09/16/2026. The policy establishes coverage limits for ABA initial assessments (24 units/6 hours) and reassessments (16 units/4 hours every 6 months), with defined exception criteria for complex cases including regression, comorbid conditions, major treatment changes, severe behaviors, language barriers, and multi-system coordination. Billing teams must implement prior authorization requirements and ensure documentation supports medical necessity for any units exceeding standard limits.
Oklahoma SoonerCare · Identified Sep 12, 2026Medium impact
Provider Letter 2026-15: Re: Provider Contract Processing Update
The Oklahoma Health Care Authority (OHCA) has announced a provider contract processing update addressing significant delays in contract reviews. They have reduced the backlog by 40% and expect to return to normal processing times by mid-October 2026. OHCA will establish a process for providers to resubmit claims that were previously denied due to delayed contract approvals.
Molina Healthcare · Effective Oct 26, 2026Medium impact
08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD
Molina Healthcare is launching a new Provider Network Management Portal on October 26, 2026, that will replace email and paper-based provider enrollment and credentialing submissions for directly contracted providers. All direct provider enrollment and credentialing requests must be submitted through this new portal starting that date. This change does not affect delegated IPAs (which use D360) or Availity functionality (claims, prior auth, member panels).
UnitedHealthcare · Identified Sep 2, 2026High impact
Hereditary cancer testing policy reminder
UnitedHealthcare is reminding providers that multigene RNA panel testing for hereditary cancer is considered unproven and will be denied. Only DNA-only hereditary cancer panels and single-gene RNA testing remain covered under applicable medical policy and prior authorization requirements.
Humana · Effective Sep 2, 2026Medium impact
Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA (Revised)
Humana Oklahoma Medicaid updated its DME/MSEA coverage policy effective 09/02/2026, establishing specific medical necessity criteria for durable medical equipment and supplies. The policy clarifies coverage determinations, repair/replacement guidelines (5-year useful lifetime), and explicitly lists equipment as either covered (with conditions) or non-covered. Key non-covered items include UpSee Mobility Devices, rolling shower chairs, safety sleep beds, and overbed tables.
Humana · Effective Sep 2, 2026Medium impact
Genetic Testing for Diagnosis of Inherited Conditions - MEDICAID - OKLAHOMA (New)
Humana Oklahoma Medicaid has released a new genetic testing coverage policy (effective 09/02/2026) that establishes medical necessity criteria and coding requirements for genetic testing to diagnose inherited conditions including adrenoleukodystrophy, corneal dystrophy, hemophilia B, myotonic dystrophy, and other genetic disorders. Billing teams must ensure pre- and post-test genetic counseling documentation and verify specific clinical criteria are met before submitting claims for covered genetic tests.
Devoted Health · Identified Aug 13, 2026Medium impact
Q2 2024 newsletter
Historical material: this Devoted Health provider newsletter (Q2 2024, June news) says Devoted Health is partnering with a payment integrity vendor in Q3 to expand its payment integrity programs, and that the vendor is an industry expert in genetic testing and infectious disease. The source says to expect edits on related claims from the vendor partner on a pre-pay basis. The newsletter also says HCC risk adjustment scoring for 2024 is 67% V28 and 33% V24, shifting to 100% V28 in 2025.
Devoted Health · Effective Aug 1, 2025Low impact
Q3 2025 newsletter
Devoted Health's Q3 2025 provider newsletter (recorded issue date 2025-07-01, first detected August 2026) covers prior authorization tips, a Stars PCP visit gap report that replaced quarterly CAHPS scorecards as of August 1, 2025, a fraud alert about fake requests for patient records, and billing rules for members with Medicaid. Its items are historical, so each should be checked against current Devoted requirements before it is acted on.
Devoted Health · Identified Aug 13, 2026Medium impact
Q2 2026 newsletter
Devoted moves electronic payments and remittance advice to a Devoted-sponsored ePayment Center, in partnership with Zelis, in September 2026, instead of Payspan, and the claim submission process does not change. Providers who order, refer, prescribe, or attend Medicaid beneficiaries must be enrolled in the state Medicaid program, at least on a ROPA (Ordering, Referring, Prescribing, or Attending) basis, if they treat members enrolled in a Medicare Advantage Special Needs Plan or members with secondary coverage through Medicaid Fee-For-Service or a Medicaid Managed Care Organization. Short-acting insulin now requires pharmacies to identify the method of administration, which determines whether the claim falls under Part B (Durable Medical Equipment) or Part D.
Humana · Effective Jul 29, 2026Medium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)
Humana Medicaid Oklahoma has established a NEW coverage policy for Fractional Flow Reserve with Computed Tomography (FFRCT), effective 07/29/2026. This is a brand new policy (not a revision) that defines specific medical necessity criteria for CPT 75580, including required CCTA-confirmed stenosis ranges (40-90%), risk stratification, and explicit exclusion criteria. Billing teams must implement prior authorization requirements and ensure provider documentation meets the defined clinical criteria.
Oklahoma SoonerCare · Effective Sep 1, 2026High impact
Provider Letter 2026-14: Re: Applied Behavior Analysis Service Quality Reviews
OHCA is implementing a mandatory Service Quality Review (SQR) process for all Applied Behavior Analysis (ABA) providers effective September 2026. Non-compliance may result in penalties, billing retractions, or referrals to Program Integrity. The policy identifies 10 specific compliance concerns including uncertified staff, inadequate documentation, misaligned CPT billing, unsigned treatment plans, and billing-documentation mismatches.
Oklahoma SoonerCare · Identified Jul 28, 2026Low impact
Provider Letter 2026-13: Re: Executive Order 2025-16 Attestation Update
OHCA is eliminating the separate attestation process for Executive Order 2025-16 compliance. Providers now verify compliance through routine provider enrollment and contract renewal instead of submitting separate attestations. Currently enrolled providers require no immediate action until their regular renewal cycle.
Humana · Effective Jul 29, 2026High impact
Spinal Decompression Surgery - MEDICAID - OKLAHOMA (New)
Humana Oklahoma Medicaid establishes new coverage criteria for spinal decompression surgery (laminectomy, laminotomy, foraminectomy, foraminotomy) in cervical and lumbar spine. Policy requires specific clinical documentation, imaging correlation, and 6-week conservative treatment failure for most diagnoses, with exceptions for emergent conditions (fractures, infections, tumors, cauda equina syndrome). Billing teams must ensure prior authorization submissions include required medical necessity documentation.
Humana · Effective Jul 22, 2026Medium impact
Clinical Trials Policy (Revised)
Humana revised its Clinical Trials Pharmacy Policy effective July 22, 2026, clarifying coverage criteria for routine care and services costs associated with FDA-approved and federally-funded clinical trials for cancer and life-threatening illnesses. The policy specifies what IS covered (medically necessary complications, conventional care items) and what IS NOT covered (investigational drugs themselves, data collection costs, sponsor-provided items, and non-standard services). For Medicaid members under 21 in Healthy Horizons plans, off-label/non-compendium treatments in clinical trials may be reconsidered under EPSDT criteria when no standard treatment exists.
Humana · Effective Jul 29, 2026High impact
Injections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (Revised)
Humana Oklahoma Medicaid updated its policy for chronic pain injections (epidural steroid injections, facet joint injections, sacroiliac joint injections, trigger point injections, and peripheral nerve blocks) effective July 29, 2026. The policy establishes specific coverage criteria including mandatory 4-week conservative treatment, radicular pain confirmation, imaging guidance requirements, and strict frequency/level limitations for procedures. Billing teams must ensure prior authorization compliance and proper documentation of conservative treatment attempts before claim submission.
Humana · Identified Jul 22, 2026Medium impact
Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (New)
Oklahoma Medicaid has established a new coverage policy for Fractional Flow Reserve with Computed Tomography (FFR-CT), a noninvasive diagnostic test used to evaluate coronary artery blood flow in patients with known or suspected coronary artery disease. This policy defines coverage for FFR-CT imaging when derived from cardiac computed tomography angiography (CCTA) data.
BCBS Oklahoma · Effective Jul 16, 2026Medium impact
Discuss Preventive Care with Members
This is a new preventive care guidance policy (effective July 16, 2026) from Blue Cross Blue Shield of Oklahoma encouraging providers to discuss and offer preventive services to members, including screenings, vaccines, and physical exams. The policy emphasizes documentation requirements, eligibility verification, and tracking of HEDIS quality measures for preventive care access.
Oklahoma SoonerCare · Effective Aug 1, 2026High impact
Provider Letter 2026-12: Re: D1354 Reimbursement Rate Update
Oklahoma Health Care Authority (OHCA) is reducing reimbursement rates for dental code D1354 (interim caries arresting medicament application) effective August 1, 2026. Rates are decreasing from $76.22 to $18.29 for children and from $83.93 to $20.14 for adults—a 76% reduction. Billing teams must update fee schedules and claims processing systems immediately to avoid payment delays and claim denials.
Humana · Effective Jul 8, 2026Medium impact
Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA (Revised)
Humana Medicaid Oklahoma revised its DME/MSEA coverage policy effective 07/08/2026, establishing specific medical necessity criteria for durable medical equipment. The policy clarifies coverage determinations, repair/replacement guidelines (5-year useful lifetime), and explicitly identifies non-covered items (UpSee Mobility Device, Rolling Shower Frames, Splashy Bath Seat, Oscillating Bed, Overbed Table). Billing teams must update claim adjudication rules to deny non-covered equipment and enforce documented medical necessity requirements.
Humana · Effective Jul 8, 2026Medium impact
Craniosacral Therapy - MEDICAID - OKLAHOMA (New)
Humana Medicaid in Oklahoma (Policy HUM-OK-2656-000) has established that craniosacral therapy is NOT covered and is considered not medically necessary for all members. This is a new policy effective July 8, 2026. Billing teams must deny all claims for craniosacral therapy billed under CPT 97530 or any other code, except for members under age 21 where requests must be reviewed for EPSDT medical necessity.
Humana · Effective Jul 1, 2026Medium impact
Quantity Limitation (Revised)
Humana has revised its Quantity Limitation (QL) pharmacy coverage policy effective July 1, 2026, clarifying how quantity limits are applied across Medicare and multiple state Medicaid programs. The policy standardizes QL criteria based on FDA-approved dosing, medical literature, and treatment guidelines, and establishes a formal exception process for members requiring higher quantities due to dosage titration, documented medical literature support, treatment failure, or individual member characteristics. Billing teams must ensure prior authorization requests for quantity limit exceptions include appropriate clinical documentation to support approval.
Humana · Effective Aug 28, 2010Medium impact
Drug Utilization Management and Clinical Edits Tools (Revised)
This is a guidance policy update (revised November 26, 2025) that clarifies Humana's Drug Utilization Management and Clinical Edits Tools across Medicare and multiple state Medicaid programs. The policy outlines how Humana applies prospective clinical edits (prior authorization, quantity limits, step therapy, duplication edits, drug/drug interactions, accumulation edits, and age/gender/disease/pregnancy edits) to ensure safe and cost-effective medication therapy. The policy specifies grandfathering exceptions for four drug classes (antidepressants, antipsychotics, anticonvulsants for epilepsy, antineoplastics, antiretrovirals, and immunosuppressants) and clarifies that drug samples do not count as treatment experience for prior authorization or step therapy requirements.
Humana · Effective Dec 17, 2025High impact
Medication Waste (Revised)
Humana revised its Medication Waste guidance policy (effective 12/17/2025) clarifying when single-dose vial waste can be billed with the JW modifier. Key requirement: medication administered and wasted must be billed on the same claim with detailed documentation (date, time, amount, reason), and waste cannot be billed for multi-dose vials. Any discrepancies between billed and documented amounts will result in denials unless wastage is clearly documented.
Humana · Effective Aug 1, 2025Medium impact
Clinical Trials Policy (Revised)
Humana revised its Clinical Trials Pharmacy Coverage Policy effective August 1, 2025, clarifying coverage eligibility for routine care costs in federally funded or approved clinical trials for cancer and life-threatening illnesses across multiple Medicaid states and Medicare. The policy establishes strict criteria for trial approval, distinguishes between routine care coverage and non-covered investigational costs, and includes special provisions for pediatric Medicaid members under age 21 using EPSDT guidelines.
Humana · Effective Apr 15, 2026High impact
Pediatric Antipsychotic Utilization Program (Revised)
Humana has revised its Pediatric Antipsychotic Utilization Program (effective April 15, 2026) establishing stricter prior authorization requirements for all antipsychotic medications in pediatric patients aged <6 years (requires compendia-supported diagnosis) and ≥6 years (standard coverage), plus new restrictions on concurrent antipsychotic use in patients ≥6 years. This policy applies to Florida, South Carolina, Oklahoma, and Virginia Medicaid plans and affects 60+ antipsychotic formulations across typical and atypical classes.
Humana · Effective Jan 1, 2019Medium impact
Limited Day Supply (Revised)
Humana revised its Limited Day Supply policy (effective January 1, 2019, with revision date December 24, 2025) to clarify pharmacy coverage limitations across Medicare, LINET, and four Medicaid state programs (South Carolina, Indiana, Oklahoma, Virginia). The policy restricts day supply for specialty drugs (30-day maximum), opioids, benzodiazepines, and approved non-formulary exceptions to prevent waste, abuse, and overdose risk. This is guidance documentation with no new billing codes but requires billing teams to enforce day supply limits at the point of claim adjudication.
Humana · Effective Apr 30, 2025High impact
Benzodiazepine Limited Days' Supply (Revised)
Humana has revised its benzodiazepine limited days' supply policy, effective April 30, 2025. All benzodiazepine medications across Medicare, LINET, Puerto Rico, and three state Medicaid programs (South Carolina, Oklahoma, Virginia) are now subject to strict day supply limits: 30 days for Medicare/LINET/SC/OK Medicaid, 31 days for Medicare/LINET LTC residents, and 34 days for Virginia Medicaid. This policy aims to reduce overdose risk and prevent medication waste, and applies regardless of tier or formulary coverage.
Humana · Effective Jun 10, 2026Medium impact
Antipsychotic Utilization Program (Revised)
Humana revised its Antipsychotic Utilization Program (effective June 10, 2026) to strengthen prior authorization requirements for atypical and typical antipsychotic medications in members with dementia. The policy now requires prior auth when members 65+ with dementia receive a new antipsychotic prescription without compendia-supported diagnoses (schizophrenia, bipolar disorder, Huntington's disease, Tourette's syndrome) or documented dangerous/severe dementia-related psychosis. This aligns with Beers Criteria guidance and CMS compliance efforts to reduce inappropriate antipsychotic use in elderly patients.

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Foot Bath Medications (New)

Humana Physician News: Q1 2026

Humana Physician News: Q2 2026

Humana Physician News: Q3 2026

Clinical Trials Policy (Revised)

Antipsychotic Utilization Program (Revised)

Provider Letter 2026-20: Re: Transitions of Care Guidance

Provider Letter 2026-19: Re: Provider Contracting Returned to Normal Processing Times

Previous Treatment/Prior Therapy/Trial (Revised)

Opioid Utilization Program - Morphine Milligram Equivalent (MME) edits (Revised)

Drug Utilization Management and Clinical Edits Tools (Revised)

Quantity Limitation (Revised)

Non-FDA Approved Medications (Revised)

Provider Letter 2026-18: Re: OHCA Contracting Delays: Claims Resubmission Exception Form Available

Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)

New oncology prior authorization code updates

New Digital Interfaces To Simplify Prior Authorization Requests

Previous Treatment/Prior Therapy/Trial (Revised)

Provider Letter 2026-17: Rates Calculation Correction and Claims Recycling

Drug Utilization Management and Clinical Edits Tools (Revised)

Anticholinergic Polypharmacy Agents (Revised)

Provider Letter 2026-16: Re: Billing of Peer Recovery Support Services (H2015)

Applied Behavior Analysis - MEDICAID - OKLAHOMA (New)

Provider Letter 2026-15: Re: Provider Contract Processing Update

08-28-2026 Coming soon: New provider enrollment and credentialing portal IM IE LA OC SAC SD

Hereditary cancer testing policy reminder

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA (Revised)

Genetic Testing for Diagnosis of Inherited Conditions - MEDICAID - OKLAHOMA (New)

Q2 2024 newsletter

Q3 2025 newsletter

Q2 2026 newsletter

Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (Revised)

Provider Letter 2026-14: Re: Applied Behavior Analysis Service Quality Reviews

Provider Letter 2026-13: Re: Executive Order 2025-16 Attestation Update

Spinal Decompression Surgery - MEDICAID - OKLAHOMA (New)

Clinical Trials Policy (Revised)

Injections for Chronic Pain Conditions - MEDICAID - OKLAHOMA (Revised)

Fractional Flow Reserve with Computed Tomography - MEDICAID - OKLAHOMA (New)

Discuss Preventive Care with Members

Provider Letter 2026-12: Re: D1354 Reimbursement Rate Update

Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - OKLAHOMA (Revised)

Craniosacral Therapy - MEDICAID - OKLAHOMA (New)

Quantity Limitation (Revised)

Drug Utilization Management and Clinical Edits Tools (Revised)

Medication Waste (Revised)

Clinical Trials Policy (Revised)

Pediatric Antipsychotic Utilization Program (Revised)

Limited Day Supply (Revised)

Benzodiazepine Limited Days' Supply (Revised)

Antipsychotic Utilization Program (Revised)