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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: 2026-05-006 Medical policies

Date: May 1, 2026

Effective Date: June 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 Commercial medical injectable policies, visit Prime Therapeutics. To view Medicare medical injectable policies, visit Capital’s Medicare medical policies page and click on the Medical Drugs, Biologics, and Diabetes Supplies dropdown.

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 has updated medical specialty policies (Commercial only) to be more medication-specific. The clinical criteria have been updated, along with the appearance and formatting of the policies.

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.

Note: To view Medicare medical injectable policies, visit Capital’s Medicare medical policies page and click on the Medical Drugs, Biologics, and Diabetes Supplies dropdown.

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
Exdensur^®	New	6/1/2026	J3590 and C9399 will now require PA for new drug Exdensur
Cimzia^®	Revised	7/1/2026	See updated policy for details.
Fasenra^®	Revised	7/1/2026	See updated policy for details
Nucala^®	Revised	7/1/2026	See updated policy for details
Omvoh^®	Revised	7/1/2026	See updated policy for details.
Orencia^®	Revised	7/1/2026	See updated policy for details.
Tremfya^®	Revised	7/1/2026	See updated policy for details.
Ustekinumab	Revised	7/1/2026	See updated policy for details.
Xolair^®	Revised	7/1/2026	See updated policy for details.
Aflibercept	Revised	7/1/2026	See updated policy for details.
Bevacizumab	Revised	7/1/2026	See updated policy for details.
Cabazitaxel	Revised	7/1/2026	See updated policy for details.
Cinqair^®	Revised	7/1/2026	See updated policy for details.
Darzalex Faspro^®	Revised	7/1/2026	See updated policy for details.
Entyvio^® IV	Revised	7/1/2026	See updated policy for details.
Gamifant^®	Revised	7/1/2026	See updated policy for details.
Hyaluronic Acid Derivatives	Revised	7/1/2026	See updated policy for details.
Ilumya^®	Revised	7/1/2026	See updated policy for details.
Infliximab	Revised	7/1/2026	See updated policy for details.
Keytruda^® IV	Revised	7/1/2026	See updated policy for details.
Keytruda QlexTM	Revised	7/1/2026	See updated policy for details.
Leqvio^®	Revised	7/1/2026	See updated policy for details.
LymphirTM	Revised	7/1/2026	See updated policy for details.
Paclitaxel Albumin-Bound	Revised	7/1/2026	See updated policy for details.
Pemetrexed	Revised	7/1/2026	See updated policy for details.
Proleukin^®	Revised	7/1/2026	See updated policy for details.
Provenge^®	Revised	7/1/2026	See updated policy for details.
RoctavianTM	Revised	7/1/2026	See updated policy for details.
Simponi Aria^®	Revised	7/1/2026	See updated policy for details.
Skyrizi^® IV	Revised	7/1/2026	See updated policy for details.
Tocilizumab IV	Revised	7/1/2026	See updated policy for details.
Trastuzumab IV	Revised	7/1/2026	See updated policy for details.
Yescarta^®	Revised	7/1/2026	See updated policy for details.
Portrazza^®	Retired	6/1/2026	Portrazza policy will be retired, and code J9295 will be removed from management as it has been withdrawn from the market.

Commercial effective 6/1/2026
Intraosseous Basivertebral Nerve Ablation	MP 1.124	Revised	Change in title; formerly Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation. Indications for Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty and Biacuplasty were removed. Removed procedure codes 22526 and 22527.

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

Intraosseous Basivertebral Nerve Ablation

MP 1.124

Revised

Change in title; formerly Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty, Biacuplasty and Intraosseous Basivertebral Nerve Ablation.

Indications for Percutaneous Intradiscal Electrothermal Annuloplasty, Radiofrequency Annuloplasty and Biacuplasty were removed.

Removed procedure codes 22526 and 22527.

Commercial effective 7/1/2026
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
Esophagogastroduoudenoscopy (EGD)	MP 2.402	New	New policy.

Medicare Advantage effective 7/1/2026
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
Amniotic Membrane and Amniotic Fluid	MA 1.159	New	New policy.
Applications of Bio Engineered Skin and Soft Tissue Substitutes	MA 1.158	New	New policy. Procedure codes: 15271, 15273, 15275, 15277, 15011, 15013, 15015, 15017, G0681, and G0683 will now require PA.
Products of Bio Engineered Skin and Soft Tissue Substitutes	MA 1.167	New	New policy. Procedure codes: 15271, 15273, 15275, 15277, 15011, 15013, 15015, 15017, G0681, and G0683 will now require PA.

Medicare Advantage and Commercial effective 7/1/2026
Prostate Artery Embolization	MP 4.051 MA 4.051	New	New policy.

Medicare Advantage and Commercial effective 7/1/2026

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

Prostate Artery Embolization

MP 4.051

MA 4.051

New

New policy.

Commercial retired medical policies 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
Photocoagulation Therapy for Treatment of AMD	MP 4.008	Retired	Retirement.

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Administrative bulletin: 2026-05-006 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

Policy name

Action

Effective date

Highlights

Commercial effective 6/1/2026

Policy name

Policy number

Action

Highlights

Commercial effective 7/1/2026

Policy name

Policy number

Action

Highlights

Medicare Advantage effective 7/1/2026

Policy name

Policy number

Action

Highlights

Medicare Advantage and Commercial effective 7/1/2026

Policy name

Policy number

Action

Highlights

Commercial retired medical policies effective 6/1/2026

Policy name

Policy number

Action

Highlights