Highlights

Key Updates

Administrative Digital SolutionsCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsMarch 1, 2025

Reminder: provider data attestation


What's New

Recent Updates

Products & Programs PharmacyMedicare AdvantageMay 22, 2025

New specialty pharmacy medical step therapy requirements

Effective July 1, 2025
Pavblu, Ahzantive, Enzeevu, Opuviz, and Yesafili

Policy Updates Medical Policy & Clinical GuidelinesBadgerCare Plus and Medicaid SSI ProgramsMay 21, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective June 25, 2025

Products & Programs PharmacyBadgerCare Plus and Medicaid SSI ProgramsMay 20, 2025

Prior authorization updates for medications billed under the medical benefit

Effective July 1, 2025
Tevimbra and Tyenne

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsMay 14, 2025

Carelon Medical Benefits Management, Inc. updates

Effective June 20, 2025

Policy UpdatesMedicare AdvantageMay 13, 2025

Clinical Criteria updates

Effective June 20, 2025

Education & TrainingCommercialMay 1, 2025

Streamline your prior authorizations with our digital tools

AdministrativeMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsMay 1, 2025

Additional drug codes added to medical claims edit system

Education & TrainingBadgerCare Plus and Medicaid SSI ProgramsMay 1, 2025

Enhancing your learning experience: latest updates in Provider Pathways

Policy Updates Medical Policy & Clinical GuidelinesCommercialMedicare AdvantageApril 30, 2025

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Effective August 1, 2025

Products & Programs PharmacyBadgerCare Plus and Medicaid SSI ProgramsApril 29, 2025

New preapproval requirements for Givlaari

Effective June 1, 2025

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsApril 25, 2025

Carelon Medical Benefits Management, Inc. updates

Effective June 15, 2025

Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageApril 24, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective May 25, 2025

AdministrativeCommercialApril 22, 2025

Required patient safety standards attestation

Products & Programs PharmacyMedicare AdvantageApril 18, 2025

New specialty pharmacy medical step therapy requirement

Effective June 1, 2025
Hercessi

Products & Programs PharmacyMedicare AdvantageApril 18, 2025

Specialty pharmacy preapproval list update

Effective August 1, 2025
Jubbonti; Wyost

Policy Updates Medical Policy & Clinical GuidelinesBadgerCare Plus and Medicaid SSI ProgramsApril 14, 2025

Updated Clinical Practice Guidelines now available online

Policy Updates Prior AuthorizationBadgerCare Plus and Medicaid SSI ProgramsApril 11, 2025

Prior authorization requirement changes

Effective June 1, 2025
Codes: J9248 and L5841

Policy Updates Medical Policy & Clinical GuidelinesCommercialApril 10, 2025

Medical Policies and Clinical Guidelines updates, May 2025

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsApril 3, 2025

Clinical Criteria updates

Effective May 7, 2025

Policy Updates Medical Policy & Clinical GuidelinesBadgerCare Plus and Medicaid SSI ProgramsApril 1, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective May 1, 2025

Policy Updates Reimbursement PoliciesCommercialApril 1, 2025

Clarification to reimbursement policy: Incident to Services and Billing Professional

Education & TrainingCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsApril 1, 2025

Register for our next webinar: Enhancing Diabetes Management — Focus on Standardized Metrics

Policy Updates Medical Policy & Clinical GuidelinesBadgerCare Plus and Medicaid SSI ProgramsMarch 28, 2025

Updates to Carelon Medical Benefits Management, Inc. Clinical Appropriateness Guidelines

Policy Updates Prior AuthorizationCommercialMarch 28, 2025

Streamline your workflow: Submit BH authorizations through Availity Essentials

Products & Programs PharmacyCommercialMarch 27, 2025

Specialty pharmacy updates — April 2025

Policy Updates Prior AuthorizationMedicare AdvantageMarch 27, 2025

Outpatient preapproval update from Carelon Medical Benefits Management, Inc.

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsMarch 24, 2025

Carelon Medical Benefits Management, Inc. updates

Effective on May 1, 2025

Products & Programs PharmacyMedicare AdvantageMarch 19, 2025

Medicare Part B preapproval expands with new drug additions

AdministrativeCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsMarch 19, 2025

Technical difficulties: My Diverse Patients

Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageMarch 11, 2025

Medical Policies and Clinical Utilization Management Guidelines update

Effective April 12, 2025

Policy Updates Prior AuthorizationMedicare AdvantageMarch 6, 2025

Prior authorization requirement changes
Effective July 1, 2025

AdministrativeCommercialMarch 1, 2025

Update: Drug claims edits to focus on FDA‑approved indications

Products & Programs Federal Employee Program (FEP)CommercialMarch 1, 2025

Changes in Postal Service Health Benefits for 2025

AdministrativeCommercialMarch 1, 2025

New coding guidelines: include the anatomic modifier

Education & TrainingCommercialMarch 1, 2025

You are invited: Availity Essentials overview

Administrative Digital SolutionsCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsMarch 1, 2025

Reminder: provider data attestation

Products & Programs PharmacyMedicare AdvantageFebruary 28, 2025

Important change to your patients’ specialty prescriptions

Effective April 1, 2025

Education & TrainingCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsFebruary 28, 2025

Resources to support diverse patients and communities

Administrative Digital SolutionsCommercialMedicare AdvantageBadgerCare Plus and Medicaid SSI ProgramsFebruary 28, 2025

Update: Availity launches enhanced provider enrollment features for improved efficiency

Policy UpdatesMedicare AdvantageFebruary 27, 2025

Clinical Criteria updates

Effective March 28, 2025

Policy UpdatesBadgerCare Plus and Medicaid SSI ProgramsFebruary 26, 2025

Clinical Criteria updates

Effective March 28, 2025

Products & Programs PharmacyBadgerCare Plus and Medicaid SSI ProgramsFebruary 25, 2025

Prior authorization updates for medications billed under the medical benefit

Effective April 1, 2025
Orencia and Avsola

Products & Programs PharmacyBadgerCare Plus and Medicaid SSI ProgramsFebruary 24, 2025

Prior authorization updates for medications billed under the medical benefit

Effective April 1, 2025
Tevimbra and Tyenne

Policy Updates Medical Policy & Clinical GuidelinesMedicare AdvantageFebruary 20, 2025

MCG Care Guidelines 29th edition

Effective June 1, 2025

Products & Programs PharmacyBadgerCare Plus and Medicaid SSI ProgramsFebruary 19, 2025

Prior authorization updates for medications billed under the medical benefit

Effective April 1, 2025
Anktiva, Hercessi, and Imdelltra

Policy Updates Medical Policy & Clinical GuidelinesCommercialFebruary 18, 2025

MCG Care Guidelines 29th edition

Effective June 1, 2025