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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: 2026-07-005 Medical policies

Date: July 1, 2026

Effective date: August 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
Kresladi^®	New	8/1/2026	J3590 and C9399 will now require PA for new drug Kresladi^®
Avlayah^®	New	8/1/2026	J3590 will now require PA for new drug Avlayah^®
Denosumab	Revised	8/1/2026	Q5165 (Oziltus), Q5166 (Osyvrti and Jubereq), and Q5171 (Boncresa) will now require PA as new Denosumab biosimilars
Long-acting granulocyte colony stimulating factors	Revised	8/1/2026	Q5169 will now require PA for new Neulasta biosimilar, Armlupeg
Ryplazim^®	Revised	9/1/2026	See updated policy for details.
Ustekinumab	Revised	9/1/2026	See updated policy for details.
Adcetris^®	Revised	9/1/2026	See updated policy for details.
Adstiladrin^®	Revised	9/1/2026	See updated policy for details.
Aflibercept	Revised	9/1/2026	See updated policy for details.
Amondys-45^®	Revised	9/1/2026	See updated policy for details.
Bortezomib	Revised	9/1/2026	See updated policy for details.
Briumvi^®	Revised	9/1/2026	See updated policy for details.
Darzalex^®	Revised	9/1/2026	See updated policy for details.
Darzalex Faspro^®	Revised	9/1/2026	See updated policy for details.
Elrexfio™	Revised	9/1/2026	See updated policy for details.
Elzonris^®	Revised	9/1/2026	See updated policy for details.
Empliciti^®	Revised	9/1/2026	See updated policy for details.
Enjaymo^®	Revised	9/1/2026	See updated policy for details.
Epkiney^®	Revised	9/1/2026	See updated policy for details.
Erbitux^®	Revised	9/1/2026	See updated policy for details.
Exondys-51^®	Revised	9/1/2026	See updated policy for details.
Feraheme^®	Revised	9/1/2026	See updated policy for details.
Grafapex™	Revised	9/1/2026	See updated policy for details.
Injectafer^®	Revised	9/1/2026	See updated policy for details.
Izervay™	Revised	9/1/2026	See updated policy for details.
Keytruda^®	Revised	9/1/2026	See updated policy for details.
Keytruda Qlex™	Revised	9/1/2026	See updated policy for details.
Kyprolis^®	Revised	9/1/2026	See updated policy for details.
Lemtrada^®	Revised	9/1/2026	See updated policy for details.
Lynozyfic™	Revised	9/1/2026	See updated policy for details.
Monoferric^®	Revised	9/1/2026	See updated policy for details.
Natalizumab	Revised	9/1/2026	See updated policy for details.
Ocrevus^®	Revised	9/1/2026	See updated policy for details.
Ocrevus Zunovo^®	Revised	9/1/2026	See updated policy for details.
Omisirge^®	Revised	9/1/2026	See updated policy for details.
Opdivo^®	Revised	9/1/2026	See updated policy for details.
Opdivo Qvantig™	Revised	9/1/2026	See updated policy for details.
Sarclisa^®	Revised	9/1/2026	See updated policy for details.
Scenesse^®	Revised	9/1/2026	See updated policy for details.
Spinraza^®	Revised	9/1/2026	See updated policy for details.
Talvey^®	Revised	9/1/2026	See updated policy for details.
Tecvayli^®	Revised	9/1/2026	See updated policy for details.
Tepezza^®	Revised	9/1/2026	See updated policy for details.
Tzield^®	Revised	9/1/2026	See updated policy for details.
Vabysmo^®	Revised	9/1/2026	See updated policy for details.
Viltepso^®	Revised	9/1/2026	See updated policy for details.
Vyondys 53^®	Revised	9/1/2026	See updated policy for details.
Yervoy^®	Revised	9/1/2026	See updated policy for details.
Zynyz^®	Revised	9/1/2026	See updated policy for details.

Commercial effective 8/1/2026
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
Postsurgical Home Use of Limb Compression Devices for Venous Thromboembolism	MP 6.053	Revised	Added procedure code E0683.

Commercial effective 9/1/2026
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
Biofeedback as a Treatment of Chronic Pain	MP 2.064	Revised	Change in title; formerly Biofeedback and Neurofeedback. Added statement Biofeedback as treatment of chronic pain in all other indications is investigational. Removed statements: for chronic proctalgia, Electromyography (EMG) controlled neuromuscular electrical stimulation, and childhood non-neurogenic dysfunctional voiding. Removed procedure codes: E0746, 90912 and 90913. Will be discussed in MP 2.398, MP 2.399, and MP 2.401.
Keratoprosthesis and Corneal Surgery	MP 9.011	Revised	Change in title; formerly Corneal Surgery. Updated statement for keratoprosthesis, detailed criteria is in policy guidelines. Removed procedure codes: 65760, 65765, and 65771 as they remain a benefit exclusion. Removed criteria for corneal transplant and endothelial keratoplasty. Associated procedure codes removed: 65710, 65730, 65750, 65755, 65756, 65757, and 65767.
Biofeedback as a Treatment of Fecal Incontinence or Constipation	MP 2.398	New	New policy. Biofeedback for fecal incontinence was MN, is now INV. Updated criteria and guidelines for biofeedback for constipation. Added procedure codes: 90875, 90876, 90901, 90912, and 90913.
Biofeedback as a Treatment of Headache	MP 2.400	New	New policy. Added procedure codes: E0746, 90875, 90876, and 90901.
Biofeedback as a Treatment of Urinary Incontinence in Adults	MP 2.399	New	New policy. Biofeedback for Urinary Incontinence was MN, is now INV. Added procedure codes: E0746, 90875, 90876, 90901, 90912, and 90913.
Biofeedback for Miscellaneous Indications	MP 2.401	New	New policy. Revised list of miscellaneous indications in the policy statement. Added procedure codes: E0746, 90875, 90876, and 90901.
Hematopoietic Cell Transplantation for Solid Tumors of Childhood	MP 9.054	Revised	Policy statement for recurrent osteosarcoma with bone-only metastases, recurrent high-risk, and very high-risk Wilms tumor was MN, is now INV.
Neurofeedback	MP 2.029	Reinstated	Updated statement language. Neurofeedback remains INV. Added procedure codes: 90875, 90876, and 90901.

Medicare Advantage effective 8/1/2026
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
Intraosseous Basivertebral Nerve	MA 1.124	New	New policy.

Medicare Advantage and Commercial effective 8/1/2026
Treatment of Dry Eye Syndrome	MP 4.033 MA 4.033	Revised	Change in title; formerly Diagnosis and Treatment of Dry Eye Syndrome.

Medicare Advantage and Commercial effective 8/1/2026

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

Treatment of Dry Eye Syndrome

MP 4.033

MA 4.033

Revised

Change in title; formerly Diagnosis and Treatment of Dry Eye Syndrome.

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