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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: 2026-04-004 Medical policies

Date: April 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
Yartemlea^®	New	5/1/2026	J3590 and C9399 will now require PA for new drug Yartemlea
Lunsumio Velo™	New	5/1/2026	J9350 will now require PA for new drug Lunsumio Velo
Rybrevant Faspro™	New	5/1/2026	J9999 and C9399 will now require PA for new drug Rybrevant Faspro
Aranesp^®	Revised	6/1/2026	See updated policy for details
Epoetin alfa	Revised	6/1/2026	See updated policy for details.
Mircera^®	Revised	6/1/2026	See updated policy for details.
Rivfloza^®	Revised	6/1/2026	See updated policy for details.
Adcetris^®	Revised	6/1/2026	See updated policy for details.
Adstiladrin^®	Revised	6/1/2026	See updated policy for details.
Anktiva^®	Revised	6/1/2026	See updated policy for details.
Cerezyme^®	Revised	6/1/2026	See updated policy for details.
Darzalex^® IV	Revised	6/1/2026	See updated policy for details.
Datroway^®	Revised	6/1/2026	See updated policy for details.
Enhertu^®	Revised	6/1/2026	See updated policy for details.
Erbitux^®	Revised	6/1/2026	See updated policy for details.
Fulvestrant	Revised	6/1/2026	See updated policy for details.
Ilaris^®	Revised	6/1/2026	See updated policy for details.
Inlexzo™	Revised	6/1/2026	See updated policy for details.
Jelmyto^®	Revised	6/1/2026	See updated policy for details.
Keytruda^® IV	Revised	6/1/2026	See updated policy for details.
Lunsumio™ IV	Revised	6/1/2026	See updated policy for details.
Nplate^®	Revised	6/1/2026	See updated policy for details.
Onivyde^®	Revised	6/1/2026	See updated policy for details.
Opdivo IV	Revised	6/1/2026	See updated policy for details.
Opdivo SQ	Revised	6/1/2026	See updated policy for details.
Oxlumo	Revised	6/1/2026	See updated policy for details.
Padcev^®	Revised	6/1/2026	See updated policy for details.
Perjeta^®	Revised	6/1/2026	See updated policy for details.
Rybrevant^® IV	Revised	6/1/2026	See updated policy for details.
Skysona^®	Revised	6/1/2026	See updated policy for details.
Trodelvy^®	Revised	6/1/2026	See updated policy for details.
Uplizna	Revised	6/1/2026	See updated policy for details.
Yervoy^®	Revised	6/1/2026	See updated policy for details.
Zolgensma^®	Revised	6/1/2026	See updated policy for details.
Zusduri™	Revised	6/1/2026	See updated policy for details.
Amtagvi^®	Revised	6/1/2026	C9399 will now require PA when used for Amtagvi^®
Bevacizumab	Revised	6/1/2026	C9399 will now require PA when used for Avzivi^®
Enspryng^®	Revised	6/1/2026	C9399 will now require PA when used for Enspryng^®
Kebilidi™	Revised	6/1/2026	C9399 will now require PA when used for Kebilidi™
Omisirge^®	Revised	6/1/2026	C9399 will now require PA when used for Omisirge^®
Penpulimab-KCQX	Revised	6/1/2026	C9399 will now require PA when used for Penpulimab-KCQX
Revcovi^®	Revised	6/1/2026	C9399 will now require PA when used for Revcovi^®
Rivfloza^®	Revised	6/1/2026	C9399 will now require PA when used for Rivfloza^®
Ustekinumab	Revised	6/1/2026	C9399 will now require PA when used for Starjemza™ IV and Starjemza™ SQ
IVIG	Revised	6/1/2026	C9399 will now require PA when used for Gammagard Liquid ERC^® and Qivigy^®
Denosumab	Revised	6/1/2026	C9399 will now require PA when used for Enoby™ and Xtrenbo™
Aflibercept	Revised	6/1/2026	C9399 will now require PA when used for Eydenzelt^®

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
Epidural Steroid Injections for Back Pain	4.014	Revised	Change in title; formerly Epidural Steroid Injections for Back Pain and Facet Nerve Blocks. Facet Joint Injections/Medial Branch Block indications and associated procedure codes have been removed and placed on MP 4.050.
Facet Joint Injections and Medial Branch Blocks	4.050	New	New policy. Indications and procedure codes were moved from MP 4.014.

Commercial effective 6/1/2026
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
APOS Therapy System	8.014	New	New Policy.
Substance Abuse Disorder Site of Service	4.052	New	New Policy.

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
External Infusion Pumps for Insulin Delivery and Automated Insulin Delivery Systems	6.007	Revised	Removed criteria that requires specific documentation for external pumps for Commercial. Added MN criteria for automated infusion devices for type 2 diabetes for Commercial. Procedure code E0787 will no longer require PA for MA.

Commercial retired medical policies effective 5/1/2026
Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name	Policy number	Highlights
Implantable Infusion Pumps for Pain and Spasticity	1.058	Retirement Will now be managed by TurningPoint Procedure code C9811 will no longer require PA
Interventions for Progressive Scoliosis	1.120	Retirement Procedure code L1001 has been changed from INV to covered
Intravenous Antibiotic Therapy for Lyme Disease	2.026	Retirement
Spinal Cord and Dorsal Root Ganglion Stimulation	1.069	Retirement
Vagus Nerve Blocking Therapy for Treatment of Obesity	1.146	Retirement

Medicare Advantage retired medical policies effective 5/1/2026
Abbreviations: E/I – Experimental/investigational; INV – Investigational; Local Coverage Determination –LCD; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; National Coverage Determination – NCD; NMN – Not Medically Necessary; PA – Preauthorization
Policy name	Policy number	Highlights
Photocoagulation Therapy for Treatment of AMD	4.008	Retirement

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Administrative bulletin: 2026-04-004 Medical policies

Web Content Viewer - Fixed Context

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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

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Effective date

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Commercial retired medical policies effective 5/1/2026

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