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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: 2026-08-005 Medical policies

Date: August 1, 2026

Effective date: September 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
Otarmeni^TM	New	9/1/2026	J3590 and C9399 will now require PA for new drug Otarmeni^TM
Wainua^®	New	9/1/2026	J3490 and C9399 will now require PA for new drug Wainua^®
Ranibizumab	Revised	9/1/2026	Q5168 will now require PA. for new biosimilar Nufymco^®
Trabectedin	Revised	9/1/2026	Title change, formerly Yondelis; J9999 will now require PA for new product, Evdi.
Denosumab	Revised	10/1/2026	New step therapy requirements. See updated policy for details.
Tocilizumab	Revised	10/1/2026	Updated step therapy requirements. See updated policy for details.
Long-Acting Granulocyte Colony Stimulating Factors	Revised	10/1/2026	Updated step therapy requirements. See updated policy for details.
Gemcitabine	Revised	10/1/2026	New step therapy requirements. See updated policy for details.
Inlexzo^TM	Revised	10/1/2026	New step therapy requirements. See updated policy for details.
Kyxata^TM	Revised	10/1/2026	New step therapy requirements. See updated policy for details.
Alhemo^®	Revised	10/1/2026	See updated policy for details.
Anti-Inhibitor Antibody	Revised	10/1/2026	See updated policy for details.
Factor IX^®	Revised	10/1/2026	See updated policy for details.
Factor VIIa^®	Revised	10/1/2026	See updated policy for details.
Factor VIII^®	Revised	10/1/2026	See updated policy for details.
Factor VIII-vWF	Revised	10/1/2026	See updated policy for details.
Factor X^®	Revised	10/1/2026	See updated policy for details.
Factor XIII	Revised	10/1/2026	See updated policy for details.
Factor XIIIA Subunit	Revised	10/1/2026	See updated policy for details.
Hympavzi^®	Revised	10/1/2026	See updated policy for details.
Qfitlia^TM	Revised	10/1/2026	See updated policy for details.
Von Willebrand Factor	Revised	10/1/2026	See updated policy for details.
Anti-Inhibitor Coagulant Complex	Revised	10/1/2026	See updated policy for details.
Bevacizumab^®	Revised	10/1/2026	See updated policy for details.
Bizengri^®	Revised	10/1/2026	See updated policy for details.
Crysvita^®	Revised	10/1/2026	See updated policy for details.
Enhertu^®	Revised	10/1/2026	See updated policy for details.
Kadcyla^®	Revised	10/1/2026	See updated policy for details.
Margenza^®	Revised	10/1/2026	See updated policy for details.
Ocrevus^® IV	Revised	10/1/2026	See updated policy for details.
Paclitaxel Albumin-Bound	Revised	10/1/2026	See updated policy for details.
Pemetrexed	Revised	10/1/2026	See updated policy for details.
Perjeta^®	Revised	10/1/2026	See updated policy for details.
Phesgo^®	Revised	10/1/2026	See updated policy for details.
Spevigo^®	Revised	10/1/2026	See updated policy for details.
Trastuzumab IV	Revised	10/1/2026	See updated policy for details.
Herceptin Hylecta^®	Revised	10/1/2026	See updated policy for details.
Ziihera^®	Revised	10/1/2026	See updated policy for details.

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
Bioimpedance Devices for Detection and Management of Lymphedema	MP 2.190	Revised	Updated policy to clarify medically necessary clinical scenarios.
Cochlear Implant	MP 1.023	Revised	The minimum age requirement for bilateral and unilateral cochlear implantation has been revised. Coverage eligibility has changed from 9 months of age to 7 months of age, allowing qualifying infants to be considered for implantation beginning at 7 months of age when all applicable medical necessity criteria are met.
Cosmetic and Reconstructive Surgery	MP 1.004	Revised	Added criteria for canthoplasty and canthopexy, procedure codes: 21280, 21282, and 67950, from MP 1.003. Added statement for Abdominoplasty, remains Investigational. Removed coding and criteria for pectus excavatum correction, rhinoplasty and septoplasty (procedure codes: 21740, 21742, 21743, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 03062, and 30520). Will still require prior authorization with criteria from InterQual.
Rhinomanometry and Acoustic, Optical Rhinometry	MP 2.088	Revised	Removed procedure code 92520.

Commercial effective 10/1/2026
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
Intravitreal and Punctum Corticosteroid Implants	MP 2.159	Revised	Added Iluvien to INV stance for treatment of chronic noninfectious uveitis affecting the posterior segment of the eye. Added punctum implant to stance regarding all other uses as INV.

Medicare Advantage and Commercial effective 10/1/2026
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
Focal Treatments for Prostate Cancer	MP 4.043 MA 4.043	Revised	Title change; formerly Treatment of the Prostate (Focal Water Vapor, Aquablation, and Hydrogel Spacer). Policy statements and procedure codes for water vapor and aquablation were moved to MP 4.053. Policy statements and procedure codes for hydrogel spacer moved to MP 4.054. Procedure code 0950T was moved to MP 4.002.
Hydrogel Spacer Use During Radiotherapy for Prostate Cancer	MP 4.054 MA 4.054	New	New Policy. Statements and procedure code (55874) were removed from MP 4.043 and placed into this new policy; intent unchanged.
Transurethral Water Vapor Thermal Therapy and Transurethral Water Jet Ablation (Aquablation) for Benign Prostatic Hypertrophy	MP 4.053 MA 4.053	New	New Policy. Policy statements and procedure codes moved from MP 4.043. No change to intent. Added procedure codes: C2596, 52597, 53854, and 55899 to MP 4.053. Added procedure codes: 53854 and 55899 to MA 4.053.

Commercial retired medical policies 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
Abdominoplasty and Panniculectomy	1.012	Addendum	Please note that this information was previously communicated in the June 1, 2026, Provider Communications. It will now be retired effective September 1, 2026. Abdominoplasty is discussed in MP 1.004. Panniculectomy is managed by InterQual.
Blepharoplasty, Repair of Brow Ptosis, and Reconstructive Eyelid Surgery	MP 1.003	Retired	Retirement. Procedure codes: 21280, 21282, 67950 will be moving to MP 1.004. Procedure codes: 15820, 15821, 15822, 15823, 67900, 67901, 67902, 67903, 67904, 67906, 67908, 67909, and 69711 will still be managed by InterQual.
Implantation of Intrastromal Corneal Ring Segments	MP 1.044	Retired	Retirement. Procedure code 65785 will no longer require PA.
Orthognathic Surgery	MP 1.101	Retired	Retirement. Procedure codes: 21431, 21432, 21433, 21435, 21436 will no longer require PA. Orthognathic surgery criteria will now be managed through InterQual. Procedure codes: 21125, 21127, 21141, 21142, 21143, 21145, 21146, 21147, 21150, 21151, 21155, 21159, 21160, 21188, 21193, 21194, 21195, 21196, 21198, 21199, 21206, 21208, 21209, 21210, 21215, 21244, 21245, 21246, 21247, and 21299 will still require PA.

Medicare Advantage retired medical policies effective 9/1/2026
Thermography	MA 5.017	Retirement. Please refer to the National Coverage Determination (NCD).

Medicare Advantage retired medical policies effective 9/1/2026

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

Thermography

MA 5.017

Retirement.

Please refer to the National Coverage Determination (NCD).

Commercial and Medicare Advantage retired medical policies effective 9/1/2026
Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence	MP 4.034 MA 4.034	Retirement.

Commercial and Medicare Advantage retired medical policies effective 9/1/2026

Policy name

Policy number

Highlights

Transvaginal and Transurethral Radiofrequency Tissue Remodeling for Urinary Stress Incontinence

MP 4.034

MA 4.034

Retirement.

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