Administrative bulletin: 2026-11-002 Medicare only

Date: November 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

Professional Providers only

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

Annual review and updates to Prime Therapeutics™ guidelines

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Please review updates to Capital Blue Cross’ clinical guidelines made by our vendor, Prime Therapeutics, during their annual review.

Providers are advised to share with office staff the changes made to vendors' clinical guidelines and how this may affect requests for authorization for services effective January 1, 2027.

Prime Therapeutics (Medicare) Approved clinical guidelines, effective January 1, 2027
Policy number
Policy name
Highlights

CBC Part B CGM PA

Prior authorization criteria for continuous glucose monitors (CGM) – Medicare Part B
  • Removal: Minimed Minilink from the target list.
  • Removal: Minimed Paradigm from the target list.

CBC Part B CGM Benefit Limit

Benefit limit criteria for continuous glucose monitor (CGM) – Medicare Part B
  • Removal: Minimed Minilink from the target list.
  • Removal: Minimed Paradigm from the target list.

CBC Part B DTS PA

Prior authorization criteria for diabetic testing supplies – Medicare Part B
  • Removal: OneTouch/LifeScan from preferred products.

CBC Part B DTS Benefit Limit

Benefit limit criteria for diabetic testing supplies – Medicare Part B
  • Administrative changes to wording.

MPS Medicare Part B Utilization Management Review

Medicare Part B prior authorization
  • No changes.

Capital BC Medicare Part B ST

Capital Blue Cross step therapy requirements for Medicare outpatient (Part B) medications

New codes added to new Bone-Modifying Agents category:

  • J3489 Zolendronic Acid preferred 1st line
  • Q5162 Bildyos preferred
  • Q5167 Enoby preferred
  • Q5167 Bilprevda preferred
  • Q5167 Xtrenbo preferred
  • J0897 Prolia non-preferred
  • J0897 Xgeva non-preferred
  • Q5158 Conexxence non-preferred
  • Q5158 Bomyntra non-preferred
  • Q5171 Boncresa non-preferred
  • Q5166 Jubereq non-preferred
  • Q5165 Oziltus non-preferred
  • Q5136 Jubbonti non-preferred
  • Q5136 Wyost non-preferred
  • Q5166 Osvyrti non-preferred
  • Q5157 Stoboclo non-preferred
  • Q5157 Osenvelt non-preferred
  • Q5159 Ospomyv non-preferred
  • Q5159 Xbryk non-preferred

New codes added to new Disease Modifying Autoinflammatory Agents category:

  • Q5156 Avtozma preferred
  • Q5135 Tyenne preferred
  • J3262 Actemra non-preferred
  • Q5133 Tofidence non-preferred

New codes added to new System Lupus Erythematosus category:

  • J0490 Benlysta IV preferred
  • J0491 Saphnelo IV non-preferred

Concurrent use of Opioids and Benzodiazepines (COB)

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Providers should use caution when prescribing opioids along with benzodiazepines. See below for important information regarding the CMS Medicare Part D Patient Safety Measure.

Defining the measure:

COB identifies the percentage of continuously enrolled Medicare Part D members age 18 or older who have prescription opioid and benzodiazepine supplies that overlap for at least 30 cumulative days during the measurement year. Lower rates indicate better performance.

Measure importance:

Concurrent exposure is a serious safety concern for most patients and has been associated with overdose and mortality risk.

Exclusions:

A member is excluded from the denominator when any of the following applies during the measurement period:

  • Hospice care (at least 1 day of hospice coverage).
  • Cancer diagnosis.
  • Sickle cell disease diagnosis.
  • Palliative care diagnosis.
  • Cancer-related pain treatment diagnosis.

Measure criteria:

  • Opioid criteria: At least 2 opioid prescription claims on different dates of service, at least 15 cumulative days’ supply, and the first opioid claim at least 30 days before the end of the measurement period.
  • COB numerator: At least 2 benzodiazepine prescription claims on different dates of service plus 30 or more cumulative days when opioid and benzodiazepine supplies overlap.

Medication classes:

  • Prescription opioids (examples include oxycodone, codeine and hydrocodone).
  • Benzodiazepines (examples include lorazepam, alprazolam and diazepam).

Tips and best practices:

  • Review the complete medication profile, including prescriptions from all prescribers and pharmacies, and check the Prescription Drug Monitoring Program (PDMP) when clinically appropriate.
  • Avoid or minimize opioid-benzodiazepine overlap when possible by considering safer alternatives, shorter durations, or other treatment options.
  • Coordinate care with other prescribers and pharmacies to ensure a consistent treatment plan and address potential duplicate or unintended therapy.
  • Regularly reassess therapy for ongoing need, effectiveness, adverse effects, sedation, and respiratory risk, and adjust treatment when clinically appropriate.
  • Document and manage changes carefully, including the indication, risk-benefit discussion, care coordination, monitoring plan, and any gradual tapering strategy.

Claim edit update for interprofessional consultation services

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Capital Blue Cross will update its claims processing system for Interprofessional Consultation service claims processed on or after January 1, 2027.

Interprofessional Consultation services (codes: 99446, 99447, 99448, 99449, 99451) will not be eligible for separate reimbursement when either of the following circumstances apply:

  • The consulting practitioner provided a face-to-face E/M service to the patient within the 14 days preceding the consultation.
  • The consultation results in a transfer of care or a face-to-face service with the consulting practitioner within 14 days following the consultation (or at the next available appointment).

Claims submitted under these circumstances may be denied.

Additional information

This claims processing update aligns with Current Procedural Terminology (CPT®) coding guidelines for Interprofessional Consultation services and reinforces that these services are intended for situations in which the consulting practitioner does not have a recent or imminent face-to-face relationship with the patient.

Providers should review billing practices and documentation requirements to ensure compliance with applicable CPT guidelines.

Professional Providers only

New HarmonyCares In-Home Care program

  • CHIP
  • EPO
  • FEP PPO
  • HMO
  • Medicare Advantage HMO
  • POS
  • PPO
  • Traditional and Comprehensive
  • Medicare Advantage PPO

KEY POINT: Capital Blue Cross is partnering with HarmonyCares to provide in-home visits to your most at-risk Medicare Advantage patients.

Many patients with complex health needs face barriers that make routine medical care difficult, including limited mobility, frailty, multiple chronic conditions, or transportation challenges. Through HarmonyCares, a Primary Care Medical Group Practice, eligible members can receive in-home clinical services that help reinforce treatment plans, support ongoing monitoring, and improve care coordination. Services include physician oversight and in-person care, in-home labs, imaging, 24/7 tele triage, and wraparound care coordination.

How patients are identified

Over the coming months, Capital will proactively identify, and HarmonyCares will reach out to Medicare Advantage members struggling with access to care due to frailty, mobility, transportation issues, and/or escalating chronic conditions requiring intensive management.

Providers can also refer patients who may benefit from in-home care.

Referring patients to HarmonyCares

  • Referral – Capital has developed a referral form that participating providers can use to refer Medicare Advantage individual account members who may benefit from the program. The form captures key clinical information and helps initiate an eligibility review and outreach process.
  • Eligibility review – Following a referral, HarmonyCares will perform an initial assessment and determine whether the member meets program requirements. Eligibility is based on a thoughtfully designed, data science-driven methodology that combines healthcare insights with clinical review to identify eligible members.
  • Provider support – As the primary care provider, you remain at the center of your patient’s care. By extending care into the home environment, you gain another layer of support for patients who may be at greater risk for worsening health outcomes between office visits.

Working together to improve outcomes

HarmonyCares serves as an extension of your care team. Collaboration can ensure:

  • Intensive in-home management, averaging 6 provider visits per patient per year.
  • Care transition following hospital, ED, or other care events.
  • Coordination with your team to share updates and collaborate on emerging needs.
  • Social needs are addressed by helping identify barriers and connecting patients with available resources.

If you have patients who may benefit from additional support at home, consider submitting a referral. Together, we can help ensure members receive the best clinical care and outcomes.

For more information about the program, please contact your Provider Engagement Consultant or visit the capbluecross.com Provider Engagement lookup tool to identify your designated point of contact at Capital Blue Cross.