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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: 2026-10-005 Medical policies

Date: October 1, 2026

Effective date: November 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
Sarclisa Escena^®	New	11/1/2026	J9999 and C9399 will now require PA for new drug Sarclisa Escena.
Fosaprepitant	Revised	11/1/2026	New product, Navitrux will be added to the policy
Fulvestrant	Revised	11/1/2026	New product, Cligavyx will be added to the policy
Bendamustine	Revised	12/1/2026	New step therapy requirements, see updated policy for details
Bortezomib	Revised	12/1/2026	J9041, J9046, J9048, J9049, J9054, and J9999 (bortezomib) will now require PA; new step therapy requirements, see updated policy for details
Pemetrexed	Revised	12/1/2026	J9292 (Axtle) will now require PA; new step therapy requirements, see updated policy for details
SCIG	Revised	12/1/2026	See updated policy for details.
Adcetris^®	Revised	12/1/2026	See updated policy for details.
Amvuttra	Revised	12/1/2026	See updated policy for details.
Casgevy^®	Revised	12/1/2026	See updated policy for details.
Cosela^®	Revised	12/1/2026	See updated policy for details.
Darzalex^® IV	Revised	12/1/2026	See updated policy for details.
Erbitux^®	Revised	12/1/2026	See updated policy for details.
Evkeeza^®	Revised	12/1/2026	See updated policy for details.
IVIG	Revised	12/1/2026	See updated policy for details.
Keytruda^® IV	Revised	12/1/2026	See updated policy for details.
Keytruda Qlex^™	Revised	12/1/2026	See updated policy for details.
Leqembi^® IV	Revised	12/1/2026	See updated policy for details.
Levqvio^® SQ	Revised	12/1/2026	See updated policy for details.
Opdivo^® IV	Revised	12/1/2026	See updated policy for details.
Opdivo Qvantig^™	Revised	12/1/2026	See updated policy for details.
Padcev^®	Revised	12/1/2026	See updated policy for details.
Perjeta^®	Revised	12/1/2026	See updated policy for details.
Rybrevant^® IV	Revised	12/1/2026	See updated policy for details.
Rybrevant Faspro^™	Revised	12/1/2026	See updated policy for details.
Sarclisa^® IV	Revised	12/1/2026	See updated policy for details.
Synagis^®	Revised	12/1/2026	See updated policy for details.
Tecelra^®	Revised	12/1/2026	See updated policy for details.
Tevimbra^®	Revised	12/1/2026	See updated policy for details.
Trastuzumab IV	Revised	12/1/2026	See updated policy for details.
Trodelvy^®	Revised	12/1/2026	See updated policy for details.
Vectibix^®	Revised	12/1/2026	See updated policy for details.
Xeomin^®	Revised	12/1/2026	See updated policy for details.
Yervoy^®	Revised	12/1/2026	See updated policy for details.

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
Audio Visual Neuromodulation for Neuropathic Pain	MP 6.065	New	New policy.
Permanently Implanted Prostatic Devices for Benign Prostatic Hyperplasia	MP 4.055	New	New policy.
Medical Necessity	MP 4.003	Revised	Removed the Out of Network services section.

Commercial effective 12/1/2026
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
Ankle-Foot and Knee-Ankle-Foot Orthoses	MP 6.062	Revised	Remove procedure code L2006 from PA. Will now be non-covered.
Air and Water Ambulance Services	MP 3.017	Revised	Added language specifying that non-emergent air and water ambulance transport is considered not medically necessary.
Bio-Engineered Skin and Soft Tissue Substitutes	MP 1.158	Revised	Multiple procedure codes were removed from MP 1.158 because they are already included in MP 1.159 or will be moved to MP 1.159; coverage remains unchanged. Added INV statement to read: “All other skin and soft tissue substitutes not listed above” are considered INV. Added procedure codes as INV: A2004, A2008, A2019, A2020, A2021, A2036, A2037, A2038, A2039, A2042, A6460, A6461, C1832, C9353, C9354, C9361, Q4124, and Q4238. Kerecis Omega3 (procedure codes Q1458 and A2019) are now MN for diabetic lower extremity ulcers.

Medicare Advantage and Commercial effective 12/1/2026
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	Action	Highlights
Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, Lung or Prostate	MP 1.162 MA 1.162	Revised	Change in title; formerly Irreversible Electroporation of Tumors Located in the Liver, Pancreas, Kidney, or Lung. Added prostate tumors to the INV statement. Added procedure code 55877 to the INV coding table.
Light Therapies	MP 2.046 MA 2.046	Revised	Procedure codes: 96920, 96921 and 96922, will no longer require PA. Added Ultraviolet Light A (UVA) Phototherapy to the MN statement. Updated coding tables to individualize each light therapy statement with its own procedure codes and diagnosis codes. Moved Goeckerman therapy and placed after Ultraviolet Light B (UVB) Phototherapy (UVB) therapy; editorial refinements to statement to clarify this is UVB with either tar or petroleum. Deleted targeted therapy statement. Added that excimer laser is considered targeted therapy.
Tibial Nerve Stimulation	MP 1.134 MA 1.134	Revised	Procedure code 64566 will no longer require PA for MA 1.134. Added procedure code 0590T to the MA coding table of MA 1.134. Added the device Altavivia as INV to MP 1.134 and MA 1.134. Statement “subcutaneous tibial nerve stimulation” was changed to “implantable tibial nerve stimulation” for MP 1.134 and MA 1.134.
Amniotic Membrane and Amniotic Fluid	MP 1.159 MA 1.159	Revised	Added 111 amniotic procedure codes as INV. Added investigational criteria for injectable amniotic products. Added language to clarify that human amniotic derived products are INV for indications not addressed in the policy. Added procedure codes: 15271, 15272, 15273, 15274, 15275, 15276, 15277, 15278, 65778, 65779, 65780, and 66999 representing application of the amniotic product to MP 1.159. Added procedure codes: 15275, 15276, 15277, 15278, 65778, 66779, 66780, and 66999 representing the application of amniotic products to MA 1.159. Moved procedure code Q4238 to MP 1.158 and MA 1.167.
Surgical Treatment of Sleep Apnea and Snoring	MP 1.128 MA 1.128	Revised	Added INV statement for the Genio^® Hypoglossal Nerve Stimulation (HNS) system for the treatment of clinically significant Obstructive Sleep Apnea (OSA) Syndrome to MP 1.128. Added a MN statement to now specifically cite the Inspire^® device to MP 1.128. Added procedure code 64999, as this code represents an unlisted procedure of the nervous system to MP 1.128 and MA 1.128.

Medicare Advantage effective 11/1/2026
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	Action	Highlights
Medical Necessity	MA 4.003	New	New policy.

Medicare Advantage effective 12/1/2026
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	Action	Highlights
Nonpharmacologic Treatment of Rosacea	MA 2.071	Revised	Added procedure codes 17106, 17107 and 17108 will now require PA.
Products of Bio-Engineered Skin and Soft Tissue Substitutes	MA 1.167	Revised	Multiple procedure codes were removed from MA 1.167 because they are already included in MA 1.159 or will be moved to MA 1.159; coverage remains unchanged. Kerecis Omega3 (procedure codes Q4158 and A2019) are now MN for diabetic lower-extremity ulcers. Added procedure codes as INV: A2004, A2008, A2019, A2020, A2021, A2036, A2037, A2038, A2039, A2042, A6460, A6461, C1832, C9353, C9354, C9361, Q4124, and Q4238.

Commercial retired medical policies effective 11/1/2026
Endovascular Grafts for Abdominal Aortic Aneurysms	MP 1.090	Retirement	Retirement. Procedure codes: 34701, 34703, 34705, 34707 will no longer require PA. InterQual will manage.

Commercial retired medical policies 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

Endovascular Grafts for Abdominal Aortic Aneurysms

MP 1.090

Retirement

Retirement.

Procedure codes: 34701, 34703, 34705, 34707 will no longer require PA.

InterQual will manage.

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Administrative bulletin: 2026-10-005 Medical policies

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