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Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Administrative bulletin: 2026-03-005 Medical policies

Date: March 1, 2026

Effective Date: April 1, 2026 (Unless otherwise indicated)

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Notification of new and revised medical policies and preauthorization requirements.

Professional and facility providers

Notification of new and revised medical policies and preauthorization requirements

Capital Blue Cross has updated Medical Policies as outlined below. Full details on these policy changes are available for review via the Draft medical policies page in the Provider Library. Although highlights are noted, please refer to the draft policies for updated criteria and related coding. Administrative changes to policy verbiage have also been made (e.g., changing “members” to “individuals”). These revisions do not change policy intent.

Capital's medical policies do not constitute medical advice and are not intended to govern the practice of medicine. Coverage for services may vary based on the terms of the member's benefit booklet and any applicable federal or state laws. In the event an applicable law/regulation supersedes a medical policy, such law/regulation will control.

Where To Find Policies and Codes Requiring Authorization

From the “Preauthorization and policies” section of the Provider Library, click the “Draft policies” link under the “Medical policies” heading.

To access medical injectable policies, visit Prime Therapeutics.

Codes that require preauthorization are maintained on the Capital Blue Cross single source preauthorization list located on the CapBlueCross.com provider web page.

Medical specialty injectable policies updates

Capital Blue Cross has delegated Medical specialty injectable policies to Prime Medical Pharmacy Solutions (MPS). Prime MPS is updating medical specialty policies (Commercial only) to be more medication-specific. There will be changes in the appearance and formatting of the policies, as well as updated clinical criteria.

If prior authorization is required, submit your request online via the Prime MPS GatewayPA Portal. For urgent or expedited requests, call Prime using the phone number below.

If preauthorization cannot be performed online, Prime MPS will be accepting requests via phone or fax:

Telephone: 800.424.1710.
Fax: 888.656.6671.

For further details on Medical Injectable policies (Commercial Only), please follow these instructions:

Access the Prime MPS GatewayPA Portal at http://www.GatewayPA.com.
Click on “Capital Blue Cross” under “Clinical Guidelines” on the left side of the screen to view medical policies.

To be consistent with clinical monitoring, prior authorization periods for some drugs have changed. Please see the individual drug medical policy for the length of authorization.

Policy name	Action	Effective date	Highlights
Itvisma^®	New	4/1/2026	J3590 will now require PA for new drug Itvisma
Adakveo^®	Revised	5/1/2026	See updated policy for details.
Aflibercept	Revised	5/1/2026	See updated policy for details
Bavencio^®	Revised	5/1/2026	See updated policy for details
Beqvez™	Revised	5/1/2026	See updated policy for details.
Breyanzi^®	Revised	5/1/2026	See updated policy for details.
Casgevy^®	Revised	5/1/2026	See updated policy for details.
Danyelza^®	Revised	5/1/2026	See updated policy for details.
Gemcitabine	Revised	5/1/2026	See updated policy for details.
Givlaari^®	Revised	5/1/2026	See updated policy for details.
Hemgenix^®	Revised	5/1/2026	See updated policy for details.
Imdelltra^®	Revised	5/1/2026	See updated policy for details.
Imfinzi^®	Revised	5/1/2026	See updated policy for details.
Imjudo^®	Revised	5/1/2026	See updated policy for details.
Jemperli	Revised	5/1/2026	See updated policy for details.
Libtayo^®	Revised	5/1/2026	See updated policy for details.
Loqtorzi^®	Revised	5/1/2026	See updated policy for details.
Lunsumio™	Revised	5/1/2026	See updated policy for details.
Luxturna^®	Revised	5/1/2026	See updated policy for details.
Lyfgenia^®	Revised	5/1/2026	See updated policy for details.
Omisirge^®	Revised	5/1/2026	See updated policy for details.
Penpulimab-KCQX	Revised	5/1/2026	See updated policy for details.
Polivy^®	Revised	5/1/2026	See updated policy for details.
Rituximab IV	Revised	5/1/2026	See updated policy for details.
Rituximab SQ	Revised	5/1/2026	See updated policy for details.
Roctavian™	Revised	5/1/2026	See updated policy for details.
Spinraza^®	Revised	5/1/2026	See updated policy for details.
Tecentriq^® IV	Revised	5/1/2026	See updated policy for details.
Tecentriq^® SQ	Revised	5/1/2026	See updated policy for details.
Tevimbra^®	Revised	5/1/2026	See updated policy for details.
Tzield^®	Revised	5/1/2026	See updated policy for details.
Unloxcyt™	Revised	5/1/2026	See updated policy for details.
Zolgensma^®	Revised	5/1/2026	See updated policy for details.
Zynyz^®	Revised	5/1/2026	See updated policy for details.

Commercial effective 4/1/2026
Abbreviations: E/I – Experimental/investigational; INV – Investigational; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name	Policy number	Action	Highlights
Surgical Ventricular Restoration	1.082	Revised	Change in title; formerly Surgical Treatment of Heart Failure. Policy statements removed: Contents related to partial left ventriculectomy Post infarction left ventricular aneurysm
Renal Denervation for Uncontrolled Hypertension	1.166	New	New policy.
Vertebral Fracture Assessment and Biomechanical Computed Tomography	5.046	Revised	Removed procedure code 77085.

Commercial effective 5/1/2026
Abbreviations: E/I – Experimental/investigational; INV – Investigational; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name	Policy number	Action	Highlights
Power Wheelchairs, Power Operated Vehicles (POV) and Related Options and Accessories	6.037	Revised	Procedure code E0986 will now require PA.

Medicare Advantage and Commercial effective 5/1/2026
Abbreviations: E/I – Experimental/investigational; INV – Investigational; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NMN – Not Medically Necessary; PA – Preauthorization
Policy name	Policy number	Action	Highlights
Radiofrequency Ablation of Thyroid Tumors	1.165	New	Procedure codes 60660 and 60661 are now covered and will require PA.
Diagnosis of Idiopathic Environmental Intolerance	G2056 Avalon	Revised	Replaced “In all circumstances” with “For asymptomatic individuals and/or during general encounters without abnormal findings,” for clarity of enforcement of testing. Breath hydrogen/methane testing will not be allowed under any circumstance. This was previously stated with a list of examples that did not meet the criteria
Diagnostic Testing of Iron Homeostasis and Metabolism	G2011 Avalon	Revised	Clarified frequency of testing for serum ferritin levels to no more than once per month for listed indications. Testing frequency is specified for those with chronic kidney disease, on dialysis monthly testing, no dialysis every three (3) months. For both serum ferritin and serum transferrin covered indications now include restless leg syndrome/periodic limb disorder.
Radiofrequency Ablation of Miscellaneous Solid Tumors Excluding Liver Tumors	1.084	Revised	Policy no longer includes thyroid indications and associated procedure codes (60660 and 60661) have been removed and placed on MP 1.165.
Vitamin D Testing	G2005	Revised	Added that individuals with Vitamin D deficiency must meet criteria for testing. Added chemotherapy to indications for testing. Change in testing frequency from twice per year until therapeutic goal is achieved. Annual testing once therapeutic goal is achieved, to no more than one (1) test every six (6) months.
Immune Cell Function Assay	G2098 Avalon	Annual Review. Administrative and/or formatting changes without a change in coverage or criteria may have been made to these policies.
Nerve Fiber Density Testing	M2112 Avalon
Prenatal Testing for Fetal Aneuploidy	G2055 Avalon
Testosterone	G2013 Avalon
Urinary Tumor Markers for Bladder Cancer	G2125 Avalon
Vitamin B12 and Methylmalonic Acid Testing	G2014 Avalon

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Administrative bulletin: 2026-03-005 Medical policies

Web Content Viewer - Fixed Context

Web Content Viewer - Fixed Context

Professional and facility providers

Notification of new and revised medical policies and preauthorization requirements

Where To Find Policies and Codes Requiring Authorization

Medical specialty injectable policies updates

Policy name

Action

Effective date

Highlights

Commercial effective 4/1/2026

Policy name

Policy number

Action

Highlights

Commercial effective 5/1/2026

Policy name

Policy number

Action

Highlights

Medicare Advantage and Commercial effective 5/1/2026

Policy name

Policy number

Action

Highlights