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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: 2026-09-005 Medical policies

Date: September 1, 2026

Effective date: October 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
Decnupaz^®	New	10/1/2026	J9999 and C9399 will now require PA for new drug, Decnupaz.
Waskyra^TM	New	10/1/2026	New medical necessity criteria policy.
Short-Acting Granulocyte Colony Stimulating Factors	Revised	10/1/2026	J3590 and C9399 will now require PA for new biosimilar, Filkri.
Golimumab IV	Revised	10/1/2026	Title change, formerly Simponi Aria; J3590 will now require PA for new biosimilar Immgolis Intri.
Vyvgart^® IV	Revised	10/1/2026	See updated policy for details.
Vyvgart^® Hytrulo	Revised	10/1/2026	See updated policy for details.
Fasenra^®	Revised	11/1/2026	See updated policy for details.
Hympavzi^®	Revised	11/1/2026	See updated policy for details.
Nucala^®	Revised	11/1/2026	See updated policy for details.
Vyjuvek^®	Revised	11/1/2026	See updated policy for details.
Xolair^®	Revised	11/1/2026	See updated policy for details.
Amvuttra	Revised	11/1/2026	See updated policy for details.
Bavencio^®	Revised	11/1/2026	See updated policy for details.
Botox^®	Revised	11/1/2026	See updated policy for details.
Cinqair^®	Revised	11/1/2026	See updated policy for details.
Datroway^®	Revised	11/1/2026	See updated policy for details.
Daxxify^®	Revised	11/1/2026	See updated policy for details.
Denosumab	Revised	11/1/2026	See updated policy for details.
Dysport^®	Revised	11/1/2026	See updated policy for details.
Evenity^®	Revised	11/1/2026	See updated policy for details.
Exdensur^®	Revised	11/1/2026	See updated policy for details.
Firmagon^®	Revised	11/1/2026	See updated policy for details.
Imfinzi^®	Revised	11/1/2026	See updated policy for details.
Imjudo^®	Revised	11/1/2026	See updated policy for details.
Jemperli	Revised	11/1/2026	See updated policy for details.
Krystexxa^®	Revised	11/1/2026	See updated policy for details.
Leuprolide Suspension	Revised	11/1/2026	See updated policy for details.
Levoleucovorin	Revised	11/1/2026	See updated policy for details.
Libtayo^®	Revised	11/1/2026	See updated policy for details.
Loqtorzi^®	Revised	11/1/2026	See updated policy for details.
Myobloc^®	Revised	11/1/2026	See updated policy for details.
Onpattro^®	Revised	11/1/2026	See updated policy for details.
Opdualag^TM	Revised	11/1/2026	See updated policy for details.
Palonosetron	Revised	11/1/2026	See updated policy for details.
Penpulimab-KCQX	Revised	11/1/2026	See updated policy for details.
Qalsody^®	Revised	11/1/2026	See updated policy for details.
Radicava^®	Revised	11/1/2026	See updated policy for details.
Rituximab IV	Revised	11/1/2026	See updated policy for details.
Sustol^®	Revised	11/1/2026	See updated policy for details.
Tecentriq^® IV	Revised	11/1/2026	See updated policy for details.
Tecentriq^® SQ	Revised	11/1/2026	See updated policy for details.
Tecvayli^®	Revised	11/1/2026	See updated policy for details.
Tevimbra^®	Revised	11/1/2026	See updated policy for details.
Trelstar^®	Revised	11/1/2026	See updated policy for details.
Tzield^®	Revised	11/1/2026	See updated policy for details.
Unloxcyt^TM	Revised	11/1/2026	See updated policy for details.
Vyepti^®	Revised	11/1/2026	See updated policy for details.
Xeomin^®	Revised	11/1/2026	See updated policy for details.
Zevaskyn^TM	Revised	11/1/2026	See updated policy for details.
Zofran^®	Revised	11/1/2026	See updated policy for details.
Zoladex^®	Revised	11/1/2026	See updated policy for details.
Zoledronic Acid	Revised	11/1/2026	See updated policy for details.
Zynyz^®	Revised	11/1/2026	See updated policy for details.

Commercial effective 10/1/2026
Foot Care Services	MP 2.018	Revised	Clarified diagnosis code B35.1 is covered when MN for procedure codes: 11720, 11721, G0127, G0247, and S0390. Added diagnosis code G62.82.

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

Foot Care Services

MP 2.018

Revised

Clarified diagnosis code B35.1 is covered when MN for procedure codes: 11720, 11721, G0127, G0247, and S0390.

Added diagnosis code G62.82.

Commercial effective 11/1/2026
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
Functional Neuromuscular Electrical Stimulation	MP 6.051	Revised	Added policy guidelines for multi-modal devices and supply limits. There will be no separate allowance for procedure codes: A4556, A4558 and A4630 as they are integral to procedure code A4595.
Transcutaneous Electrical Nerve Stimulation and Transcutaneous Afferent Patterned Stimulation	MP 6.020	Revised	Policy guidelines revised to include multi-modal devices and supply limits. Added procedure code A4556 and is Investigational (INV). Procedure codes A4558 and A4630 was MN and is now INV.

Commercial retired medical policies 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
Step Therapy Treatment of Stage Four, Advanced Metastatic Cancer and Severe Related Health Conditions	MP 2.373	Retired	Retirement.

Medicare Advantage effective 11/1/2026
Experimental and Investigational Procedures	MA 4.002	Revised	Removed procedure codes: 0554T, 0555T, 0557T, and 0558T. Please reference National Coverage Determination (NCD) 150.3.

Medicare Advantage effective 11/1/2026

Abbreviations: E/I – Experimental/investigational; INV – Investigational; LCD – Local Coverage Determination; MA – Medicare Advantage; MN – Medically Necessary; MP – Medical Policy; NCD – National Coverage Determination; NMN – Not Medically Necessary; PA – Preauthorization

Policy name

Policy number

Action

Highlights

Experimental and Investigational Procedures

MA 4.002

Revised

Removed procedure codes: 0554T, 0555T, 0557T, and 0558T.

Please reference National Coverage Determination (NCD) 150.3.

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Administrative bulletin: 2026-09-005 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 10/1/2026

Policy name

Policy number

Action

Highlights

Commercial effective 11/1/2026

Policy name

Policy number

Action

Highlights

Commercial retired medical policies effective 10/1/2026

Policy name

Policy number

Action

Highlights

Medicare Advantage effective 11/1/2026

Policy name

Policy number

Action

Highlights