Administrative bulletin: 2026-03-002 Medicare only

Date: March 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

Annual review and updates to Prime Therapeutics™ guidelines

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Updates have been made to Capital Blue Cross' clinical guidelines by our vendor, Prime Therapeutics.

Please share these changes with your office staff, as they could impact step therapy authorization requests effective May 1, 2026, for our Medicare Advantage members.

Prime Therapeutics Approved Clinical Guidelines, Effective May 1, 2026
Policy number
Policy name
Highlights

Capital BC Medicare Part B ST

Capital Blue Cross Step Therapy Requirements for Medicare Outpatient (Part B) Medications

New codes added to existing categories:

  • Q5160 (Monoclonal antibodies/cancer)
  • J9361 (Colony Stimulating Factors)

Administrative changes:

  • Complement Inhibitors category: removal of 'For indication of PNH or aHUS'
  • Visco supplements category: must try 2 preferred agents.

New permanent codes assigned to existing categories: Q5155 and Q5153 (Ophthalmic Injections)

New code added to preferred agents: J2182 (Asthma/COPD)

Code removed from preferred agents: J2356 (Asthma/COPD)

Prime Therapeutics (Prime) – Continuity of Care

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Prime Therapeutics (Prime) applies the following process to align with the CMS 90-day Continuity of Care (COC) rule when managing Capital's preauthorization of specialty medications routinely covered under a patient's medical benefit.

Certain medical injectable medications require preauthorization to be eligible for coverage under the medical benefit. These medications are maintained on the Capital Blue Cross Single source preauthorization list. located on Capital's provider web page, and may be updated from time to time. Preauthorization may be obtained directly through Prime via www.GatewayPa.com.

Continuity of Care:

Medicare Advantage plans must provide a 90-day transition period for members switching plans, during which prior authorization is not required for active treatments. To align with this rule, Prime allows members to continue receiving their ongoing treatment without preauthorization requirements through the following process:

  1. When an authorization request for a member who may be in this 90-day transition period is received, Prime's intake team first checks the eligibility start dates for these members.
  2. Providers are informed that the member is currently within the 90-day Continuity of Care period and that no authorization is required at this time.
  3. Prime also requests that providers submit an authorization for the member at least ten (10) calendar days before the end of the current validity period.

Note: The plan start date is not the date the member started with Capital or with Medicare. It's the date they went live with their most current Medicare Advantage plan.

  • Example: If the member was on a Capital Medicare Advantage plan last year, but switched to a different Capital Medicare Advantage plan on January 1, 2026, the member would fall into this 90-day COC window because they have a new plan.