February 2026 Provider News
Date: 02/27/26
In this issue:
- General Updates - Smoking and Tobacco Cessation, Verify Ambetter Member eligibility, Ambetter And Evolent
- Quality - Lead, BCS, COL, CWP, AWV, CAHPS
- Tribal - Resource for Assistance
- Behavioral Health - WA Behavioral Health Peer Support Services
- Clinical & Payment Policies and Prior Authorization Updates - Clinical Policy Updates
- Wellcare - Medical Clinical Policy Updates
- Apple Health Core Connections - Free Individual and Group Mentoring for Adoptees
- Training/Education - No-Cost Trauma-Focused Cognitive Behavioral Therapy, Components for Enhancing Career Experience and Reducing Trauma, Suicide prevention, ABA COE training
- Pharmacy Updates - NPI Prescriber Enforcement for Pharmacy Claims, Prolia and Xgeva Updates, April 1, 2026 Preferred Drug List Updates, Pharmacy Clinical Policy Updates, Medical Oncology Update
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General Updates
Smoking and Tobacco Cessation
Washington Apple Health (Medicaid) and Apple Health Core Connections (Foster Care) have Smoking and Tobacco Cessation Programs that have health coaches who will provide support to our members who are ready to quit smoking, vaping, or chewing tobacco which can be harmful to their health. AHCC (Foster Care) Tobacco Cessation Program also offers customized help for teens wanting to quit.
We accept referrals from our members and providers via phone or e-mail.
- Washington Apple Health (Medicaid):
- Toll-Free: 1-866-274-5791
- E-mail: caremanagement@coordinatedcarehealth.com
- Apple Health Core Connections (Foster Care):
- Toll-Free: 1-844-882-3827
- E-mail: ahccteam@coordinatedcarehealth.com
Puff Free Pregnancy Program - Start Smart for Your Baby:
Case Management and support for our member’s pregnancy includes smoking cessation assistance.
E-mail: WASSFB@centene.com
Tobacco Cessation/Smoking Deterrent Medications:
- Coordinated Care (Apple Health) Preferred Drug List (PDF)
- Coordinated Care (Apple Health Expansion) Preferred Drug List (PDF)
To see the latest quarterly changes to the PDL, please review Coordinated Care’s Drug List Updates (PDF)
Verifying Ambetter from Coordinated Care Member Eligibility & Claims Risk
As a valued partner, we’re committed to supporting smooth, efficient business operations as we begin the new year. To help start the year off right, we’d like to share a few helpful reminders and tips to support seamless interactions and transactions with Ambetter.
Before rendering services, please remember to verify three key items for every Ambetter member:
- Member Eligibility Status
- Premium Paid Through Date
- Claims Paid Through Date
These items can be verified through Availity Essentials and other Ambetter from Coordinated Care secure portals.
Why This Matters
Marketplace members are responsible for paying monthly premiums. Members who miss payments may enter a Grace Period, which can affect whether claims are paid, pended, or denied—especially depending on whether the member receives an Advanced Premium Tax Credit (APTC).
Claims submitted for dates of service during a Grace Period may:
- Be considered for payment
- Be placed in a pending (pend) status
- Be denied if the member does not return to good standing and coverage is terminated
Understanding Eligibility Statuses
When reviewing eligibility, you may see the following:
- Active – Member is in good standing; premiums paid
- Active – Pending Investigation (Availity only) – Member is behind on premiums
- Delinquent (non-Availity portals) – Member is behind on premiums; Claims Paid Through Date is in the future
- Suspended (non-Availity portals) – Member is behind on premiums; Claims Paid Through Date is in the past
- Inactive – Coverage terminated; member is no longer eligible
The Premium Paid Through Date shows the last date premiums were paid.
The Claims Paid Through Date shows the last date of service for which claims will be paid or considered for payment.
Claims for dates of service after the Claims Paid Through Date are at risk for pending or denial if the member does not pay outstanding premiums.
Seeing Members Not in Good Standing
If a member is not in good standing with premium payments:
- Providers may collect full billed charges at the time of service.
- If the member later pays outstanding premiums and coverage is reinstated, a claim may be submitted.
- If that claim is paid, the provider must reimburse the member in accordance with the Provider Agreement.
Members with Active – Pending Investigation, Delinquent, or Suspended statuses should be referred to their responsibilities outlined in the Ambetter from Coordinated Care Member Handbook.
Need Help?
If you have questions about eligibility verification, Grace Period rules, claims submission, or using Availity Essentials or legacy portals, we are here to help.
For any other questions please reach out to your provider engagement administrator which can be found on our regional guide.
Or send a secure message through the provider portal.
Ambetter and Evolent-radiation oncology services
Ambetter from Coordinated Care has partnered with Evolent, a leading oncology quality management company, to implement a new prior authorization program designed to streamline administrative processes and support the delivery of high-quality, evidence-based cancer care.
Effective June 1, 2026, radiation oncology services will require a prior authorization from Evolent before being administered in either provider office, outpatient hospital or ambulatory infusion center. Treatment plans will be reviewed using nationally recognized evidence-based guidelines.
Prior authorization requirements will apply to Ambetter adult members, ages 21 and older, for ordering provider oncology specialties:
- Gynecology Oncology
- Hematology Oncology
- Medical Oncology
- Neuro Oncology
- Radiation Oncology
- Surgical Oncology
- Urology
Evolent offers providers:
- Real-time authorizations for approvable treatment plans submitted via the Evolent on-line portal.
- A telephonic option for requests at 1-888-999-7713, (Radiation Oncology, option 3). Staff are available Monday-Friday, from 5:00 a.m. to 5:00 p.m. PST.
- Real-time member eligibility verification through the Evolent CarePro portal prior to entering a treatment plan.
- Radiation oncologists on staff for clinical discussions with physicians.
Ambetter approvals issued before June 1, 2026, are effective until the authorization end date. Upon expiration, authorization requests must be submitted to Evolent. If authorization is not obtained from Evolent, claims may be denied. Radiation oncology services/treatment that did not require an authorization prior to June 1, 2026, will require an authorization from Evolent for service/treatment dates on and after June 1, 2026.
Training sessions will be scheduled for several dates beginning in May. For more details and information on registration, please visit the Evolent webpage. Should you have any questions prior to the training sessions, please contact Evolent at 1-888-999-7713, (Option 6) or via email providertraining@evolent.com.
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Quality
Medicaid Quality
Blood Lead Screening Provider Update: Washington State Lowers Blood Lead Action Level to 3.5 µg/dL
Effective February 5, the Washington State Department of Health (DOH) will lower the state blood lead action level to 3.5 micrograms per deciliter (µg/dL).
There is no safe level of lead in a child’s blood. Lowering the action level allows for earlier identification of children with elevated blood lead levels and supports prompt intervention to prevent further exposure.
Your Role as a Provider
Providers are essential in identifying and supporting children with elevated blood lead levels. Even low levels of lead exposure can impact a child’s cognitive development, behavior, and long-term health. Young children are particularly vulnerable due to developing brains and frequent hand-to-mouth activity.
DOH recommends that all children with risk factors, including those outside of Apple Health (Medicaid), be tested according to the state’s clinical algorithm.
DOH Guidance
- Begin confirmatory and follow‑up testing at 3.5 µg/dL.
- Local health jurisdictions (LHJs) may also provide follow‑up services starting at this level, based on local capacity.
- Laboratory reporting requirements remain unchanged.
Federal Medicaid guidelines require blood lead testing for:
- All Medicaid‑enrolled children at 12 and 24 months, or
- At least once before age 72 months if they have no documented prior test.
Please note:
A risk screening questionnaire does not meet this federal requirement. Only a blood lead test satisfies the mandate.
HEDIS Update for Measurement Year 2026 – Lead Screening in Children (LSC‑E)
The Lead Screening in Children (LSC‑E) measure will transition from the Hybrid methodology to Electronic Clinical Data Systems (ECDS) reporting.
This means screenings will only be captured if they are documented using:
- Correct CPT/HCPCS codes,
- Lab results with appropriate LOINC codes, or
- Entries in structured EHR data fields.
Provider Resources:
- Lead Testing for Children Enrolled in Medicaid (PDF)
- WA DOH Blood Lead Testing Information for Healthcare Providers
- Core Set Data Dashboard
- Clinical Algorithm (PDF)
Breast Cancer Screening (BCS)
Aside from some forms of skin cancer, breast cancer is the most common cancer among American women, regardless of race or ethnicity.1 Screening can improve outcomes: Early detection reduces the risk of dying from breast cancer and can lead to a greater range of treatment options and lower health care costs.
- Centers for Disease Control and Prevention (CDC). 2018. “Breast Cancer Statistics.”
- American Cancer Society. 2017. “American Cancer Society Recommendations for the Early Detection of Breast Cancer.”
Colorectal Cancer Screening (COL)
Treatment for colorectal cancer in its earliest stage can lead to a 90 percent survival rate after five years. However, more than a third of adults 50–75 do not get recommended screenings.1 Colorectal cancer screening of asymptomatic adults in that age group can catch polyps before they become cancerous or detect colorectal cancer in its early stages, when treatment is most effective.
- American Cancer Society. 2017. “Colorectal Cancer Facts & Figures 2017-2019.” (PDF)
Appropriate Testing for Pharyngitis (CWP)
Pharyngitis is one of the most common causes of ambulatory health care utilization and can be caused by both bacterial and viral infection. Pharyngitis is the only condition among upper respiratory infections (URI) where diagnosis is validated easily and objectively through administrative and laboratory data, and it can serve as an important indicator of appropriate antibiotic use among all respiratory tract infections (1). While pharyngitis is typically caused by a viral infection, it can also be caused by a bacterial infection of group A streptococcus. To limit unnecessary antibiotic use for pharyngitis caused by viruses, clinical practice guidelines recommend that patients presenting with pharyngitis only receive antibiotics if a group A streptococcal test indicates bacterial infection.
- Clinical Guidance for Group A Streptococcal Pharyngitis. Centers for Disease Control and Prevention. Updated March 1, 2024. Accessed April 7, 2025.
- Mustafa, Z. & M. Ghaffari. 2020. “Diagnostic Methods, Clinical Guidelines, and Antibiotic Treatment for Group A Streptococcal Pharyngitis: A Narrative Review.” Front Cell Infect Microbiol 10:563627. doi: 10.3389/fcimb.2020.563627
- Shulman, S.T., A.L. Bisno, H.W. Clegg, et al. 2012. “Clinical Practice Guideline for the Diagnosis and Management of Group A Streptococcal Pharyngitis: 2012 Update by the Infectious Diseases Society of America.” Clinical Infectious Diseases 55:e86–102
- Dooling, K.L., D.J. Shapiro, C. Van Beneden, et al. 2014. “Overprescribing and Inappropriate Antibiotic Selection for Children with Pharyngitis in the United States, 1997-2010.” JAMA Pediatrics 168:1073–4.
Introducing CAHPS:
CAHPS stands for Consumer Assessment of Healthcare Providers and Systems.
Every year, a random sample of health plan members is surveyed about their experience with their doctors, services, and health plan. It is an important component of ensuring that patients are satisfied, not only with their health outcomes but also with their healthcare experience. CAHPS surveys allow patients to evaluate the aspects of care delivery that matter the most to them. Every year, CAHPS surveys go out to sampled members covered under Medicare, Medicaid and Marketplace.
The following domains are directly driven by the providers:
- Getting Appointments and Care Quickly
- Getting Needed Care
- Care Coordination
- How Well Doctors Communicate
- Overall Rating of Personal Doctor
- Overall Rating of Specialist Seen Most Often
- Overall Rating of Health Care
- Annual Flu Shot
Examples of questions related to these domains include: How often do you get care as quickly as you needed; How easy was it to get care, tests and treatment when needed; How often did your PCP seem informed about the care you received about the care you received from other providers, etc.
With your attention and care, we hope to provide positive healthcare experience for our members. Studies have shown – happy members tend to have better health outcomes.
Please reach out to your provider engagement representative for questions
Wellcare Quality
Colorectal Cancer Screening (COL)
Assesses adults 50–75 who had appropriate screening for colorectal cancer with any of the following tests: annual fecal occult blood test, flexible sigmoidoscopy every 5 years, colonoscopy every 10 years, computed tomography colonography every 5 years, stool DNA test every 3 years.
Treatment for colorectal cancer in its earliest stage can lead to a 90 percent survival rate after five years. However, more than a third of adults 50–75 do not get recommended screenings.1 Colorectal cancer screening of asymptomatic adults in that age group can catch polyps before they become cancerous or detect colorectal cancer in its early stages, when treatment is most effective.
- American Cancer Society. 2017. “Colorectal Cancer Facts & Figures 2017-2019.” (PDF)
Annual Wellness Visits
Annual Preventative Wellness Visits (APV) are an opportunity to close clinical HEDIS measure gaps, establish or strengthen your Provider/Patient rapport and most importantly provide quality health care including early detection to save lives. The AWV helps develop or update a Personalized Prevention Plan (PPP) and perform a Health Risk Assessment (HRA).
Resources for Annual Wellness Visits: helpful resource tools for the AWV can be found here.
CMS website Medicare Learning Network documents 12 defined components of the First Annual Wellness Visit and subsequent Annual Wellness Visits having 11 components. Preparing eligible Patients for the AWV can include encouraging them to bring to their appointment at a minimum:
- Medical records, including immunization records
- Detailed family health history
- Full list of medications and supplements, including calcium and vitamins, and how often and how much of each they take
- Full list of current providers and suppliers involved in their care, including community-based providers (for example, personal care, adult day care, and home-delivered meals), and behavioral health specialists
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Tribal
Resource for Assistance
IHCPs have access to a dedicated email inbox for inquires regarding all lines of business at Coordinated Care (Medicaid, Marketplace/Exchange, and Medicare Advantage). Please don’t hesitate to reach out to IndianHealthCareProviderAssistance@coordinatedcarehealth.com and the team monitoring the inbox will assist or connect you with the appropriate contacts to resolve your questions.
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Behavioral Health
Washington Behavioral Health Peer Support Services
Member and Provider Information (PDF)
What are Peer Support Services?
Peer Support Services are community support services that provide help to people with behavioral health conditions, such as substance use or mental health conditions. A Certified Peer Support Specialist is someone who has also lived with a behavioral health condition. They use their own experiences and training to help others who are living with similar conditions reach their health goals. Peer Support Services can be available at any time during a person’s care.
Peer Support Services may include:
- Helping people, families, and caregivers find their way through the healthcare system to access clinical and community services.
- Working together with a person’s care team, case workers, and providers to make sure they get the help they need.
- Sharing helpful tools, skills, supports, and resources that can help people reach their health goals.
- Helping people feel hopeful, confident, and motivated during their care journey.
Peer Support Resources
- A Common Voice, the Center of Parent Excellence (C.O.P.E.) - Peer Support Services for parents and caregivers
- Behavioral Health Agencies Directory - list of licensed providers offering Peer Support Services in WA (PDF)
- Clubhouse International - Peer-Led Support and Resources
- Dads MOVE - Family-Centered Peer Services and Education
- Health Care Authority Peer Support and counseling - overview of Peer Support Services in WA
- NAMI Peer Led Connection and Family Led Support Groups
- Peer Washington - connect to Peer Support Services in WA
- Recovery Café - Peer Support and Community Building
- Teen Link - teen Peer Support Services help line
- Warm Line - Peer Support Services help line
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Clinical & Payment Policies and Prior Authorization Updates
Clinical Policy Updates
The following policies are updated as of the listed Effective Date.
Policies are posted on the Coordinated Care of Washington Policy webpage. Evolent policies are available and will be accessible via the Evolent landing page found on the Coordinated Care Prior Authorization webpage.
New to List? | Policy # | Policy Title | Line of Business | Change Type | Effective Date |
X | CP.MP.98 | Urodynamic Testing | Apple Health, Ambetter | Revised | 3/1/2026 |
X | CP.MP.99 | Wheelchair Seating | Ambetter | Revised | 3/1/2026 |
X | WA.CP.BH.104 | Applied Behavior Analysis Therapy | Apple Health | Revised | 3/1/2026 |
CP.MP.185 | Skin Substitutes for Chronic Wounds | Ambetter | Revised | 4/1/2026 | |
CP.MP.188 | Pediatric Oral Function Therapy | Apple Health, Ambetter | Revised | 4/1/2026 | |
CP.MP.247 | Transplant Service Documentation Requirements | Apple Health, Ambetter | Revised | 4/1/2026 | |
CP.MP.248 | Facility Based Sleep Studies for Obstructive Sleep Apnea | Ambetter | Revised | 4/1/2026 | |
CP.BH.105 | Applied Behavioral Analysis Documentation Requirements | Apple Health, Ambetter | Revised | 5/1/2026 | |
CP.MP.168 | Biofeedback | Ambetter | Revised | 5/1/2026 | |
CP.MP.180 | Implantable Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea | Ambetter | Revised | 5/1/2026 | |
CP.MP.185 | Skin Substitutes for Chronic Wounds | Ambetter | Revised | 5/1/2026 | |
CP.MP.190 | Outpatient Oxygen Use | Ambetter | Revised | 5/1/2026 | |
CP.MP.91 | Obstetrical Home Health Care Programs | Ambetter | Revised | 5/1/2026 | |
WA.CP.MP.117 | Peripheral and Percutaneous Electrical Nerve Stimulation | Apple Health, Ambetter | Revised | 5/1/2026 | |
X | CP.BH.124 | ADHD Assessment and Treatment | Apple Health, Ambetter | Revised | 6/1/2026 |
X | CP.MP.38 | Ultrasound in Pregnancy | Apple Health | Revised | 6/1/2026 |
X | WA.CP.MP.38 | Ultrasound in Pregnancy | Ambetter | Revised | 6/1/2026 |
X | ECG_7000 | Evolent - Radiation Therapy Services | Ambetter | New | 6/1/2026 |
X | ECG_7001 | Evolent - Proton Beam Radiation Therapy and Neutron Beam Radiation Therapy Services | Ambetter | New | 6/1/2026 |
Prior Authorization Updates
Future changes to Pre-Authorization requirements are noted below. Utilize our Pre-Auth Check tool for real time response to pre-authorization requirements.
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Wellcare
Medical Clinical Policy Updates
View the Wellcare website to see upcoming clinical policy updates and changes going into effect April 8th and April 20th
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Apple Health Core Connections
Coordinated Care has partnered with Adoptee Mentoring Society to provide no-cost individual and group mentoring for adoptees from foster care ages 12-18. One-on-one virtual mentorship offers adoptees a space to explore their adoption story with trained mentors who listen, reframe, and provide helpful resources. These 45-minute sessions empower adoptees to shape their own narratives while discussing identity, birth family, race, gender, and more. Equally important, mentorship creates space for joy – sharing hobbies, laughter, and everyday moments. This is a non-clinical resource that provides space for adoptees to connect with people with shared experiences either with individually with a trained adult adoptee or with a group of peers facilitated by Angela Tucker. You can refer members to info@adopteementorship.org or https://www.adopteementorship.org/ to learn more.
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Training/Education
No-Cost Trauma-Focused Cognitive Behavioral Therapy (TF-CBT): Coordinated Care is hosting a no-cost Trauma Focused Cognitive Behavioral Therapy Training in person on May 4-5, 2026 from 8:30AM – 5:00PM at Community Health Care in Puyallup, WA. TF-CBT is an evidenced based treatment for children and adolescents (ages 3-18) impacted by trauma that includes participation by their parents or caregivers. This training is open to contracted, in-network Coordinated Care providers and all Indian Health Care Providers with a master's degree or above in a mental health discipline, professional licensure (or under supervision for licensure), and actively treating children/adolescents involved in the child welfare system. As part of the certification, providers must commit to and participate in the follow-up TF-CBT Consultation Call Program. Participants must also complete two pre-training requirements. Providers may receive 14 CEUs. Learn more and register here.
Components for Enhancing Career Experience and Reducing Trauma (CE-CERT): Staff retention, burnout and secondary trauma are epidemic for organizations and staff working with exploited and trauma exposed populations. Regrettably the best advice usually offered is: “Do more self-care!” Keeping good staff means more than just ‘surviving’ and ‘not burning-out’. A new evidence-informed model, Components for Enhancing Career Experience and Reducing Trauma (CE-CERT), is a skills-based approach identifying five key clinical practice and supervision skills. Objectives include:
- Increase awareness of how developing experiential engagement around negative emotions plays a role in job satisfaction.
- List five key skills for managing intense affect and reducing post-work agitation.
- Understand how intense negative feelings can be "metabolized" so they do not produce negative and long-term effects.
- Have opportunity to commit to one or more key strategies that will change the participant's way of engaging in their work when they return to direct service activities.
Join this virtual training on May 13, 2026 from 8:30AM – 4:30PM. Providers may receive 6.5 CEUS. Learn more and register here.
Suicide Prevention Provides an overview of the topic of suicide, signs and symptoms, and how caregivers should respond in times of crisis. The training will dive into the rates of youth suicide, risk factors, and proactive steps to take for prevention. Mar 23, 2026 01:00PM – 2:30PM Register.
Trauma Informed Care & Discipline: We all need discipline in our lives to function well in society. For youth especially, boundaries and consistency help provide safety and security. How does a caregiver or professional provide consequences to a child who is not attached to the foster family, and has significant trauma in their lives? This training discusses this topic with ideas and tips, as well as an overview of why children with traumatic history can be so challenging! Training content partly developed from National Child Traumatic Stress Network. Mar 17, 2026 01:00 - 03:00pm Register.
Centers of Excellence Offers a One Day Training for providers interested in becoming an ABA COE on Friday, March 6, 2026, 8:30am-4:30pm
Autism Centers of Excellence Training is open to health care professionals who are pursuing diagnosis certification, and, to non-diagnosing professionals working in the health care industry such as registered nurses, care coordinators, case managers, claims staff, etc.
While the COE training certifies eligible providers to diagnose autism spectrum disorders for pediatric patients with Medicaid, it is the COE’s hope that non-diagnosing staff will join the training as it provides valuable insight and connections between those who work with our most vulnerable clients.
COE training focuses on current research and thinking regarding the evaluation, treatment, and continuing care for autistic individuals throughout the lifespan:
- Getting support from your administration
- Screening, evaluation, and diagnosis
- Differential diagnosis and co-occurring diagnoses
- Diagnostic evaluation models
- Treatment options including accessing Applied Behavior Analysis (ABA)
- Accessing community and state resources
- Documentation, billing codes, and orders
- Lived experience perspectives from autistic and family advocates
- Advice from current community COE clinicians
- ECHO Autism Washington and other follow up support
- Q & A and connect with regional partners
Non-diagnosing individuals do not need to complete the AAP online learning modules before the training. Simply register online and attend the one-day training.
Please also note that the COE has provided a link to the COE Quick Start Guide (PDF) here.
Please follow the link for more information including registration and COE contacts for questions.
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Pharmacy Updates
NPI Prescriber Enforcement for Pharmacy Claims
Action Required: In accordance with 42 CFR 438.602(b), all prescribers must be enrolled with the Health Care Authority (HCA). Effective April 1, 2026, any prescription submitted by a prescriber not recognized by the HCA will be rejected at pharmacy point of sale, some exceptions may apply. Please visit HCA's website for more information on how to enroll as a provider with the HCA.
Prolia and Xgeva Updates
As of 01/16/2026, Prolia and Xgeva are non-preferred. The biosimilars listed below are preferred.
Drug Name | Drug Class | Preferred Alternative(s) |
Prolia (denosumab) | ENDOCRINE AND METABOLIC AGENTS - MISC. – Bone Density Regulators | Bildyos (denosumab-nxxp), Enoby (denosumab-qbde), Jubbonti (denosumab-bbdz), and Ospomyv (denosumab-dssb) |
Xgeva (denosumab) | ENDOCRINE AND METABOLIC AGENTS - MISC. – Bone Density Regulators | Bilprevda (denosumab-nxxp), Wyost (denosumab-bbdz), Xtrenbo, and (denosumab-qbde) |
April 1, 2026 Preferred Drug List Updates
Effective April 1, 2026, the drugs listed below will be non-preferred. Impacted members will be notified prior to this change. Preferred alternatives are listed in the last column.
Drug Name | Drug Class | Preferred Alternative(s) |
Adderall XR CAPS (Amphetamine-Dextroamphetamine) | ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS- Amphetamines | Amphetamine-Dextroamphetamine CAPS (generic for Adderall XR) |
Concerta TABCR (Methylphenidate HCl) | ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS- Stimulants Misc. | methylphenidate hcl TABS SA OSM (generic for Concerta) |
RELEXXII TABCR (Methylphenidate HCl) | ADHD/ANTI-NARCOLEPSY/ANTIOBESITY/ANOREXIANTS- Stimulants Misc. | methylphenidate hcl TABS SA OSM (generic for Relexxii) |
LANTUS SOLN (Insulin Glargine INJ) | ANTIDIABETICS- Insulin | Insulin Glargine SOLN (interchangeable biosimilar for Lantus) |
Entresto TABS (Sacubitril-Valsartan) | CARDIOVASCULAR AGENTS – MISC.- Combinations | Sacubitril-Valsartan TABS (generic for Entresto) |
Pharmacy Clinical Policy Updates
The following pharmacy policies have been updated or will be new. Policies will be posted on the policy site, including a description of revisions here.
Policy Number | Policy Title | Updated Policy Revisions | Effective Date | Line of Business |
CP.PHAR.103 | Immune Globulins
| Removed HCPCS code [J1572] | 02/01/2026 | Medicaid |
CP.PHAR.446 | Flibanserin (Addyi)
| RT4: added population expansion to include postmenopausal women < 65 years of age (previously limited to premenopausal women only) | 02/01/2026 | Medicaid |
HIM.PA.169 | Berotralstat (Orladeyo)
| RT4: updated to reflect pediatric extension down to 2 years of age and added new oral pellet dosage form | 02/01/2026 | Ambetter |
HIM.PA.178 | Immune Globulins
| HCPCS code removed [J1572] | 02/01/2026 | Ambetter |
CP.PHAR.526
| Fibrinogen Concentrate [Human] (Fibryga, RiaSTAP), Fibrinogen, Human-chmt (Fesilty)
| RT4: added newly approved Fesilty | 02/01/2026 | Ambetter |
CP.PHAR.468
| Aducanumab-avwa (Aduhelm) | Removed HCPCS code [J0172] | 02/01/2026 | Ambetter |
CP.PHAR.600 | Trofinetide (Daybue)
| RT4: added new Daybue Stix formulation; revised approval durations to 12 months | 02/01/2026 | Ambetter |
CP.PHAR.620 | Pirtobrutinib (Jaypirca)
| RT4: for CLL/SLL, updated FDA Approved Indication(s) section to reflect conversion from accelerated approval to full approval; for CLL/SLL, simplified prior therapy requirements to “Member has received prior treatment with a covalent BTK inhibitor” per updated prescribing information and simplified Richter’s transformation requirement per NCCN compendium; for all indications, extended initial approval duration from 6 to 12 months | 02/01/2026 | Ambetter |
CP.PHAR.720
| Nipocalimab-aahu (Imaavy)
| HCPCS code updates: added [J9256], removed [C9305] | 02/01/2026 | Ambetter |
CP.PHAR.458 | Inebilizumab-cdon (Uplizna)
| RT4: added criteria for the newly approved indication of gMG; for NMOSD and IgG4-RD, extended initial approval durations for Medicaid and HIM from 6 to 12 months and revised all approval durations for Commercial to “6 months or to the member’s renewal date, whichever is longer” | 02/01/2026 | Ambetter |
CP.PMN.91 | Cariprazine (Vraylar)
| RT4: updated criteria with pediatric extension to include age 10 years and older for bipolar disorder and age 13 years and older for schizophrenia (both previously approved only in adults) per PI; added new 0.5 mg and 0.75 mg capsule strengths per PI | 02/01/2026 | Ambetter |
CP.PHAR.558 | Mitapivat (Pyrukynd, Aqvesme)
| RT4: added Aqvesme for treatment of anemia in adults with thalassemia to policy | 02/01/2026 | Ambetter |
CP.PMN.170 | Eluxadoline (Viberzi)
| Corrected numbering of criteria | 02/01/2026 | Ambetter |
CP.PHAR.422
| Cladribine (Mavenclad)
| For brand Mavenclad requests, added redirection to generic per SDC request | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.629
| Retifanlimab-dlwr (Zynyz)
| RT4: updated FDA Approved Indication(s) section for MCC from accelerated approval to full approval per PI; extended Medicaid and HIM initial approval durations from 6 months to 12 months for this maintenance medication for a chronic condition; for MCC, added pathway for in-transit regional disease and primary regional disease per NCCN compendium and removed requirement of “Disease is not amenable to surgery or radiation therapy” for metastatic or recurrent locally advanced disease per PI | 02/01/2026 | Medicaid & Ambetter |
CP.PMN.199
| Esketamine (Spravato) | HCPCS codes updates: added [J0013], removed [S0013] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.385 | Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq)
| In Section V, clarified maximum dose is every 6 months | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.495 | Mitomycin Instillation Solution (Jelmyto, Zusduri)
| HCPCS code added [J9282] and removed [J9999, C9399] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.609 | Prademagene Zamikeracel (Zevaskyn)
| Added Coding Implications section with HCPCS code [J3389] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.634 | Epcoritamab-bysp (Epkinly)
| RT4: updated with newly approved indication of combination with lenalidomide and rituximab for relapsed or refractory FL and updated accelerated approved to traditional approval for FL indications; expanded monotherapy option for B-cell lymphoma subtypes per NCCN; summarized NCCN and FDA-approved uses for improved clarity; extended initial approval duration for Medicaid/HIM from 6 months to 12 months | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.733 | Telisotuzumab Vedotin-tllv (Emrelis)
| HCPCS code updates: added [J9326], removed [C9306, J9999] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.743 | Linvoseltamab-gcpt (Lynozyfic) | HCPCS code added [C9307] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.82 | Collagenase Clostridium Histolyticum (Xiaflex)
| Added clarification for New York Essential Plans and New York Medicaid (including CHIP), use of Xiaflex for the treatment of Peyronie’s Disease is a benefit exclusion and will NOT be authorized per state regulations |
| Medicaid & Ambetter |
CP.PMN.156 | Perampanel (Fycompa) | Clarified required use of generic perampanel tablets for brand tablet and oral solutions requests | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.05 | Hyaluronate Derivatives | HCPCS code description revised [J7322] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.136 | Elagolix (Orilissa), Elagolix/Estradiol/Norethinedrone (Oriahnn)
| Repeated total duration of therapy by dosage language from approval duration in continued therapy criteria for endometriosis pain per request from UM team and canned text team | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.556 | Elivaldogene Autotemcel (Skysona)
| HCPCS code update: added [J3387], removed [J3590, C9399] | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.759 | Nerandomilast (Jascayd) | RT4: added newly FDA approved indication for PPF. | 02/01/2026 | Medicaid & Ambetter |
CP.PHAR.93 | Bevacizumab (Alymsys, Avastin, Avzivi, Jobevne, Mvasi, Vegzelma, Zirabev)
| HCPCS code added [Q5160] | 02/01/2026 | Medicaid & Ambetter |
LOB: Ambetter
Title: Medical Oncology Update
Prior Authorization requests for the following HCPCS codes need to be verified by Evolent.
HCPCS | Generic Name | Brand Name | Medical PA | Pharmacy PA | Impact Description |
J3590 | DENOSUMAB-MOBZ BONCRESA | BONCRESA | Yes | Yes | • FDA new release/approval 12/22/2025 • Biosimilar to Prolia (already in-scope, has PA) • Centene PA effective date 7/1/26
|
J3590 | DENOSUMAB-MOBZ OZILTUS | OZILTUS | Yes | Yes | • FDA new release/approval 12/22/25 • Biosimilar to Xgeva (already in-scope, has PA) • Centene PA effective date 7/1/26 |
J3590 | FILGRASTIM-LAHA INJECTION | FILKRI | Yes | Yes | • FDA new release/approval 1/15/26 • Biosimilar to Neupogen (already in-scope, has PA) • Centene PA effective date 7/1/26 |
J3590 | PEGFILGRASTIM-UNNE INJECTION | ARMLUPEG | Yes | Yes | • FDA new release/ approval 11/28/25 • Biosimilar to Neulasta (Already in-scope, has PA) • Centene PA effective date 7/1/26 |
J9999 | AMIVANTAMAB AND HYALURONIDASE-LPUJ INJECTION | RYBREVANT FASPRO | Yes | Yes | • FDA new release/approval 12/17/25 • Centene PA effective date 7/1/26 |
J9999 | MELPHALAN (IVRA) INJECTION | IVRA | Yes | Yes | • Added to Evolent review scope beginning 1/1/26 • Other melphalan codes J9245, J9246, J9247, J9248 (Already in- scope, has PA) • Centene PA effective date 7/1/2026 |
J9999 | MOSUNETUZUMAB-AXGB LUNSUMIO VELO INJECTION | LUNSUMIO VELO | Yes | Yes | • FDA new release/approval 12/19/25 • Centene PA effective date 7/1/26 |
Participating providers should submit oncology/supportive drug authorization for members through Evolent.