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C9399

PAYER POLICY CHANGES

C9399 Insurance Policy Changes

HCPCS C9399 is officially defined as "Unclassified drugs or biologicals." HCPCS C9399 is referenced in 50 tracked payer policy changes from Aetna, Capital Blue Cross, and 9 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS C9399 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

Aetna · Effective Nov 14, 2026High impact
OfficeLink Updates - August 2026 notices and reminders (PDF)
Aetna precertification applies to Ranluspec, Tregzi and Decnupaz effective August 1, 2026, and to Sarclisa Escena and Revtorpyk effective September 1, 2026. Effective November 1, 2026, CPT 77436 (SGRT) is limited to one reimbursement for the entire course of treatment, and Site of Care precertification applies to commercial Oziltus (Q5165); beginning November 14, 2026, professional claims for CPT 90963 to 90966 with an inappropriate place of service may result in claim denial. New Claim and Code Review Program edits may appear beginning November 23, 2026, and global maternity codes are retired beginning January 1, 2027.
Capital Blue Cross · Effective Dec 1, 2026High impact
AB2026-11-005 Medical policies
Capital Blue Cross administrative bulletin 2026-11-005, dated November 1, 2026, lists medical policy updates with an effective date of December 1, 2026 unless otherwise indicated. Changes effective December 1, 2026 include added procedure codes in the Durable Medical Equipment policy and new preauthorization requirements for several Prime Therapeutics injectables. Many other changes take effect January 1, 2027, including EviCore's Clinical Guidelines for Lab Management Program, Version 1.0.2027, updated Evolent radiology and radiation oncology guidelines, and updated TurningPoint musculoskeletal and cardiology policies.
Anthem BCBS · Effective Dec 1, 2026High impact
[New York] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield is implementing new prior authorization and quantity limit requirements for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty medications. Billing teams must begin requesting prior authorization for affected medications on or after the effective date, and include NDC codes on claims to expedite processing. Previously covered patients may lose coverage if prior authorization is not obtained.
Anthem BCBS · Effective Dec 1, 2026High impact
[Ohio] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements and quantity limits for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for eleven additional specialty medications. Billing teams must begin requesting prior authorization for these drugs on or after the effective date, and include NDC codes on claims to expedite processing.
Anthem BCBS · Effective Dec 1, 2026High impact
[Virginia] Specialty pharmacy updates
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements for 5 specialty pharmacy drugs effective December 1, 2026, adding quantity limits for 3 of those drugs, and revising clinical criteria for 11 existing specialty medications. Patients currently receiving these medications without prior authorization will require prior auth requests going forward. Inclusion of NDC codes on claims will expedite processing for drugs billed with NOC codes.
Anthem BCBS · Effective Dec 1, 2026High impact
[Georgia] Specialty pharmacy updates
Anthem Blue Cross Blue Shield Georgia is implementing new prior authorization and quantity limit requirements for 5 specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty drugs. Billing teams must request prior authorization for affected medications and include NDC codes on claims to expedite processing; previously covered patients may require new authorization for continued medication use.
Aetna · Effective Jan 1, 2027High impact
OfficeLink Updates - November 2026 notices and reminders (PDF)
Aetna's November 2026 OfficeLink newsletter, issued 2026-11-01, covers several changes with different dates. The biggest is a restructuring of maternity care coding, with global maternity codes retired and replaced by service-based codes effective January 1, 2027, plus a transition period for prenatal preventive visits that began September 1, 2026. It also adds precertification for several specialty drugs on staggered dates from November 1, 2026 through February 1, 2027, and notes a Medicare MolDX molecular testing Z-code requirement that has no stated date and an observation reminder that is already in effect.
Anthem BCBS · Effective Jan 1, 2027High impact
[New York] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (New York) is expanding its specialty pharmacy precertification requirements for Medicare Advantage plans. Effective January 1, 2027, step therapy will be added to the precertification review process for 10 Part B medications (denosumab, bendamustine, and pemetrexed formulations). Additionally, effective February 1, 2027, three new Part B drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will be included in the precertification review process. Noncompliance with these requirements may result in claim denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Ohio] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective February 1, 2027, three new Part B drugs (golimumab, bevacizumab, and isatuximab) will require prior authorization. Additionally, effective January 1, 2027, step therapy requirements are being added to eight existing Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate formulations). Noncompliance with precertification requirements may result in claim denial.
Anthem BCBS · Effective Jan 1, 2027High impact
[Virginia] Specialty pharmacy precertification list expands
Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective January 1, 2027, step therapy precertification will apply to multiple Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate products). Additionally, effective February 1, 2027, three new specialty drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will require precertification review. Noncompliance with these new requirements may result in claim denial.
Sentara Health Plans · Effective Jan 1, 2027High impact
Authorization Updates - Effective January 1, 2027
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
Aetna · Effective Jan 1, 2027High impact
OfficeLink Updates - October 2026 notices and reminders (PDF)
Already effective September 1 and October 1, 2026, Aetna requires precertification for drugs including Lytenava, Tudriqev, Genglycos, Pasatru, Zanvastro, and Elzonris, and requires Site of Care review for Zimrixby, Jobevne, and Avzivi. Precertification is no longer required for commercial members for OrthoVisc, Zarxio, several bortezomib products, and Fusilev, and it is no longer required for Medicare for several bortezomib products and Fusilev. Effective January 1, 2027, trauma response charges reported with revenue codes 0681 through 0684 will be denied unless a paid HCPCS code G0390 and a paid qualifying ambulance transport charge are billed on the same date of service.
Anthem BCBS · Effective Feb 1, 2027High impact
[Ohio] Specialty pharmacy updates — November 2026
Anthem Blue Cross and Blue Shield (Ohio) is implementing multiple specialty pharmacy utilization management updates effective on staggered dates: step therapy requirements for denosumab biosimilars effective November 1, 2026, and prior authorization, quantity limits, site-of-care restrictions, and clinical criteria revisions for 24 specialty medications effective February 1, 2027. Billing teams must update systems to enforce these requirements for affected HCPCS and CPT codes to avoid claim denials.
UnitedHealthcare · Effective Jan 1, 2027Medium impact
Medicare Part B Step Therapy Programs
UnitedHealthcare's October 2026 Medicare Advantage bulletin revises its Medicare Part B step therapy program, which sets preferred and non-preferred drugs for certain oncology, osteoporosis, testosterone and iron-related drugs, effective January 1, 2027. It adds newly listed generic and branded products with HCPCS codes, moves some bone density products between preferred and non-preferred, and updates the list of plans excluded from the policy.
Medicare/CMS - Transmittals · Effective Jan 1, 2027Medium impact
R13958CP: January 2027 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files
Medicare Part B drug payment limits are updated quarterly. The January 2027 average sales price (ASP) and not otherwise classified (NOC) drug pricing files set the payment limits for claims with dates of service from January 1, 2027 through March 31, 2027, along with revised October 2026, July 2026, April 2026 and January 2026 files if they are released. Each file contains the applicable payment allowance limit (106% of ASP, 106% of wholesale acquisition cost, or 95% of average wholesale price), so Medicare contractors make no additional payment calculations.
Anthem BCBS · Effective Nov 1, 2026High impact
[New York] Specialty pharmacy updates — November 2026
Anthem is implementing multiple specialty pharmacy review requirements for New York commercial plans, effective on two dates: November 1, 2026 for step therapy updates affecting denosumab biosimilars, and February 1, 2027 for prior authorization, quantity limits, site-of-care, and clinical criteria updates affecting multiple specialty drugs including golimumab, bevacizumab, isatuximab, and denosumab products. Billing teams must update workflows to obtain prior authorization and verify quantity limits before claim submission for affected medications.
Anthem BCBS · Effective Nov 1, 2026High impact
[Virginia] Specialty pharmacy updates — November 2026
Anthem Blue Cross and Blue Shield is implementing multiple specialty pharmacy management updates for Virginia, effective on two dates: step therapy requirements begin November 1, 2026, while prior authorization, quantity limits, site-of-care reviews, and clinical criteria revisions take effect February 1, 2027. Providers must request prior authorization for specified medications and adhere to new quantity limits and step therapy protocols for affected specialty pharmacy codes.
Anthem BCBS · Effective Nov 1, 2026High impact
[Georgia] Specialty pharmacy updates — November 2026
Anthem Blue Cross and Blue Shield (Georgia) is implementing multiple specialty pharmacy management updates effective on two dates: November 1, 2026 for step therapy reviews, and February 1, 2027 for prior authorization, quantity limits, site-of-care reviews, and clinical criteria revisions. Billing teams must update workflows to require prior authorization and apply quantity limits for specified biosimilar and specialty drugs, and verify step therapy requirements for denosumab products before those dates.
Capital Blue Cross · Effective Nov 1, 2026High impact
AB2026-10-005 Medical policies
Capital Blue Cross updated its medical policies with an effective date of November 1, 2026 unless otherwise indicated, and many revisions take effect December 1, 2026. Changes include new prior authorization for J9999 and C9399 (Sarclisa Escena) effective November 1, 2026, and for J9041, J9046, J9048, J9049, J9054 and J9999 (bortezomib) and J9292 (Axtle) effective December 1, 2026, along with new step therapy requirements for several drugs. Other revisions remove prior authorization for procedure codes 34701, 34703, 34705, 34707, 96920, 96921, 96922 and 64566, add prior authorization for 17106, 17107 and 17108, and list L2006 as non-covered once it is removed from prior authorization.
Independence Blue Cross · Effective Oct 19, 2026High impact
08.00.46f, Isatuximab-irfc (Sarclisa®, Sarclisa Escena)
Independence Blue Cross updated policy 08.00.46f to add coverage for a new subcutaneous formulation of isatuximab-irfc (Sarclisa Escena), approved by FDA on July 9, 2026, for multiple myeloma treatment. The policy also expanded coverage criteria for the intravenous formulation (Sarclisa) to include additional primary therapy regimens and added coverage for plasma cell-related conditions (POEMS, MIDD, MGRS). New HCPCS and ICD-10 diagnosis codes have been added to support billing for both formulations.
Florida Blue · Effective Oct 1, 2026High impact
Medicare Part B Step Therapy Oct Updates
Florida Blue Medicare has updated its Part B Step Therapy program effective October 1, 2026, restructuring preferred and non-preferred medication classifications across six drug categories (Autoimmune Therapy, Bone Remodeling Agents, Cancer and Supportive Therapy, Colony-Stimulating Factors, Complement Inhibitors, and Ophthalmic Agents). Billing teams must verify that prescriptions align with updated preferred product lists and implement prior authorization requirements for non-preferred medications to prevent claim denials.
UnitedHealthcare · Effective Oct 1, 2026High impact
Provider Administered Drugs – Site of Care
UnitedHealthcare revised its Provider Administered Drugs – Site of Care policy, reorganizing applicable medications, adding six new drugs (Avlayah, Loargys, Bosaya, Conexxence, Exdensur, Ospomyv, Qivigy), and clarifying medical necessity criteria for outpatient hospital facility infusions versus alternative sites of care. The policy now includes specific oncology drug criteria and limits outpatient hospital facility infusion duration to 6 months maximum.
UnitedHealthcare · Effective Oct 1, 2026High impact
Provider Administered Drugs – Site of Care
UnitedHealthcare revised its Provider Administered Drugs – Site of Care policy effective October 1, 2026, reorganizing drug coverage lists and adding six new medications (Avlayah, Bosaya, Conexxence, Exdensur, Ospomyv, Qivigy). The policy now requires medical necessity documentation for outpatient hospital facility infusion services, with specific clinical criteria that must be met; alternative sites of care (physician office, home infusion, ambulatory suites) are preferred unless medically contraindicated. Approval for hospital-based infusion is limited to 6 months maximum, requiring reassessment of patient eligibility.
Capital Blue Cross · Effective Oct 1, 2026High impact
AB2026-09-005 Medical policies
Capital Blue Cross has updated 50+ medical specialty injectable policies and several general medical policies effective October 1 and November 1, 2026. New prior authorization requirements apply to Decnupaz (J9999, C9399) and new biosimilars Filkri and Immgolis Intri. Medical specialty injectable policies have been delegated to Prime Therapeutics (MPS) with updated clinical criteria and a new online submission portal (GatewayPA). Billing teams must identify affected injectable medications in their patient population and implement new prior authorization workflows.
Blue Cross Blue Shield of North Dakota · Effective Oct 1, 2026High impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota's August 2026 pharmacy update covers Medicaid Expansion medical drug prior authorization policies, with new policies and coding changes effective October 1, 2026. The most important billing change is the new HCPCS codes that replace older codes, such as Q5172 for Filkri and J9362 for Yondelis, plus added diagnosis codes for several drugs; the commercial pharmacy policies were reviewed with no changes listed.
Anthem BCBS · Effective Oct 1, 2026High impact
[New York] Specialty pharmacy updates — July 2026
Anthem Blue Cross and Blue Shield is implementing new prior authorization requirements and quantity limits for four specialty pharmacy drugs effective October 1, 2026. Additionally, clinical criteria updates for eight drug categories may result in previously covered services now being found not medically necessary. Providers must begin obtaining prior authorization for affected medications on or after the effective date, and should include NDC codes on claims to expedite processing.
Anthem BCBS · Effective Oct 1, 2026High impact
[Ohio] Specialty pharmacy updates — July 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements for four specialty pharmacy drugs, quantity limits for two drugs, and updated clinical criteria that may result in previously covered services being denied. Billing teams must begin requesting prior authorization for Fesilty, Loargys, Vykoura, and Vykoura (with oncology managed separately by Carelon), and include NDC codes on claims to expedite processing of NOC-billed drugs.
Anthem BCBS · Effective Oct 1, 2026High impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements, quantity limits, and updated clinical criteria for specialty pharmacy drugs effective October 1, 2026. Four drugs now require prior authorization (Fesilty, Loargys, Vykoura, and Leucovorin calcium), two drugs are subject to quantity limits (Loargys and Yuviwel), and eight clinical criteria documents have been updated that may result in previously covered services being denied as not medically necessary. Billing teams must begin requesting prior authorizations for affected specialty pharmacy claims and ensure NDC codes are included on claims using NOC billing codes.
Anthem BCBS · Effective Oct 1, 2026High impact
[Georgia] Specialty pharmacy updates — July 2026
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) is implementing new prior authorization requirements for four specialty pharmacy drugs (Fesilty, Loargys, Vykoura, and Yuviwel), adding quantity limits to two drugs (Loargys and Yuviwel), and updating clinical criteria for eight drug classes that may result in previously covered services being denied as not medically necessary. Providers must begin requesting prior authorization for affected specialty medications on or after the effective date, and including NDC codes on claims will expedite processing.
Capital Blue Cross · Effective Sep 1, 2026High impact
AB2026-08-005 Medical policies
Capital Blue Cross updated its medical policies, with most changes effective 9/1/2026 or 10/1/2026, and several policies were retired effective 9/1/2026. Capital has delegated medical specialty injectable policies to Prime Medical Pharmacy Solutions (MPS), which revised the Commercial policies to be more medication-specific with updated clinical criteria, and several drug policies now require prior authorization for new products or add new step therapy requirements effective 10/1/2026. Other changes include a cochlear implant age change from 9 months to 7 months, added canthoplasty and canthopexy criteria in the cosmetic and reconstructive surgery policy, and new policies for transurethral water vapor thermal therapy and aquablation and for hydrogel spacer use during radiotherapy for prostate cancer.
Independence Blue Cross · Effective Aug 24, 2026High impact
08.02.49b, Pembrolizumab and berahyaluronidase alfa-pmph (Keytruda QLEX™)
Independence Blue Cross updated policy 08.02.49b to establish coverage for pembrolizumab and berahyaluronidase alfa-pmph (Keytruda QLEX™) as a subcutaneous substitute for intravenous pembrolizumab across multiple cancer indications, with treatment duration capped at 24 months per FDA and NCCN guidelines. The policy adds HCPCS code J9277 and removes two unclassified drug codes (C9399, J3590), effective 08/24/2026.
Capital Blue Cross · Effective Aug 1, 2026High impact
AB2026-07-005 Medical policies
Capital Blue Cross added or revised medical policies and preauthorization requirements, with changes dated August 1, 2026 or September 1, 2026. Preauthorization is required for Kresladi (J3590 and C9399), Avlayah (J3590), three denosumab biosimilars (Q5165, Q5166 and Q5171) and Armlupeg (Q5169) starting August 1, 2026. Many specialty injectables were revised effective September 1, 2026, E0683 was added to the postsurgical limb compression device policy for Commercial effective September 1, 2026, and keratoprosthesis codes 65760, 65765 and 65771 were removed because they remain a benefit exclusion.
Anthem BCBS · Effective Aug 1, 2026High impact
[Virginia] Specialty pharmacy updates for May 2026
Effective August 1, 2026, Anthem Virginia is implementing prior authorization, quantity limits, step therapy, and site of care requirements for 13 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before dispensing and verify medical necessity documentation. Patients currently receiving these medications without prior auth will need authorization for continued coverage.
Anthem BCBS · Effective Aug 1, 2026High impact
[Georgia] Specialty pharmacy updates for May 2026
Effective August 1, 2026, Anthem Georgia is implementing new prior authorization, quantity limit, step therapy, and site of care requirements for 17 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before the effective date, as patients currently receiving these medications without authorization will now require approval for continued use.
Independence Blue Cross · Effective Jul 27, 2026High impact
MA08.063i, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)
Independence Blue Cross updated Medicare Advantage policy MA08.063i to add coverage for Poherdy (pertuzumab-dpzb), a new FDA-approved biosimilar to Perjeta. The policy title was changed to reflect both drugs, and two new HCPCS codes (C9399 and J3590) were added to represent Poherdy. Coverage criteria for pertuzumab were expanded to align with FDA labeling and NCCN guidelines for breast cancer, CNS, colon cancer, appendiceal adenocarcinoma, biliary, and rectal cancers.
Independence Blue Cross · Effective Jul 27, 2026High impact
08.01.07l, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb (Poherdy)
Independence Blue Cross updated policy 08.01.07l to add coverage for Poherdy (pertuzumab-dpzb), the first FDA-approved biosimilar to Perjeta, effective July 27, 2026. Two new HCPCS codes (C9399 and J3590) were added to represent Poherdy claims. Coverage criteria were also updated to align with current FDA labeling and NCCN guidelines for breast cancer, CNS, colon, appendiceal, biliary, and rectal cancers.
Arkansas Blue Cross Blue Shield · Effective Jul 15, 2026High impact
Payment Policy Material Amendment
Arkansas Blue Cross and Blue Shield has published a new payment policy for mastectomy and breast reconstruction procedures under Arkansas Act 561, effective July 15, 2026. The policy requires manual review for specific surgical procedures and mandates reimbursement at 100% or greater of acquisition cost for required supplies, with providers needing to submit itemized invoices for mesh and nerve graft materials.
Blue Cross Blue Shield of North Dakota · Effective Jul 14, 2026High impact
Pharmacy Policy Updates
Blue Cross Blue Shield of North Dakota revised many Commercial prior authorization medical drug policies, with revisions effective July 14, 2026, including new or expanded indications for drugs such as Cosentyx, Darzalex SQ, Keytruda IV and Opdivo IV and changes to length of authorization durations. The same notice lists Commercial post service claim edit policy revisions effective June 1, 2026, and Commercial medical drug coding updates effective July 1, 2026 that add new HCPCS codes for denosumab biosimilars, Armlupeg, Starjemza, Eydenzelt and others and discontinue unclassified code J3590 for several of them.
BCBS Michigan · Effective Jul 1, 2026High impact
HCPCS replacement codes established, effective July 1, 2026
Effective July 1, 2026, CMS has established five new HCPCS procedure codes to replace generic placeholder codes (C9399, J3490, J3590, J9999) for five specialty biosimilar drugs: YARTEMLEA, Starjemza, Jubereq/Osvyrti, Enoby/Xtrenbo, and Eydenzelt. All services on or after July 1, 2026 must use the new specific codes (J1289, Q5164, Q5166, Q5167, Q5170). Prior authorization is required for all codes unless the member's group has opted out of the Medical Benefit Drug program.
Independence Blue Cross · Effective Jul 1, 2026High impact
MA00.005at, Experimental/Investigational Services
Independence Blue Cross updated its Experimental/Investigational Services policy effective 07/01/2026, adding 32 new CPT codes, 3 new HCPCS codes, and 2 new unlisted code services (VersaWrap and Stravix Nerve Wrap) to the non-covered list, while removing 6 CPT codes and 1 HCPCS code that are now eligible for coverage. Billing teams must update claims systems to deny claims for newly added experimental codes and allow claims for newly eligible codes.
Independence Blue Cross · Effective Jul 1, 2026High impact
12.01.01bu, Experimental/Investigational Services
Independence Blue Cross updated its Experimental/Investigational Services policy effective 07/01/2026, adding 30 new CPT codes, 3 new HCPCS codes, and 2 unlisted service categories (VersaWrap and Stravix Nerve Wrap) to the non-covered list. Additionally, 5 CPT codes, 3 HCPCS codes were removed as now eligible for coverage, and 1 CPT code was terminated. Billing teams must update their denial rules and billing software to reflect these changes immediately.
Independence Blue Cross · Effective Jul 1, 2026High impact
MA08.042l, Ustekinumab for Intravenous Use
Independence Blue Cross Medicare Advantage is replacing two NOC codes (C9399, J3590) with a single HCPCS code (Q5164) for Starjemza (ustekinumab-hmny) effective 07/01/2026. This billing code change affects how ustekinumab biosimilar claims are submitted and requires system updates to use the new specific product code instead of unclassified drug/biologic codes.
Independence Blue Cross · Effective Jul 1, 2026High impact
MA08.148d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)
Independence Blue Cross is updating coding for Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) effective July 1, 2026. Two unclassified codes (C9399 and J3590) are being removed and replaced with a single specific HCPCS code J9062. Billing teams must update their systems to use the new code for all Rybrevant Faspro claims to avoid denials.
Independence Blue Cross · Effective Jul 1, 2026High impact
08.00.82q, Ustekinumab for Intravenous Infusion
Effective 07/01/2026, Independence Blue Cross is updating policy 08.00.82q to replace NOC codes C9399 and J3590 (used for Starjemza ustekinumab-hmny) with the specific HCPCS code Q5164. This billing code change ensures accurate claims submission for the biosimilar ustekinumab-hmny (Starjemza) for intravenous infusion. The policy maintains ustekinumab-kfce (Yesintek) as the preferred product with clear nonpreferred alternatives requiring prior authorization for coverage.
Independence Blue Cross · Effective Jul 1, 2026High impact
08.01.23k, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur)
Effective July 1, 2026, Independence Blue Cross is replacing unclassified drug codes (C9399, J3590) with a specific HCPCS code (J2361) for depemokimab-ulaa (Exdensur), a new IL-5 antagonist for severe eosinophilic asthma. Billing teams must update systems to use J2361 instead of the old codes to ensure proper claim processing and reimbursement.
Independence Blue Cross · Effective Jul 1, 2026High impact
08.02.53a, Belantamab mafodotin-blmf (Blenrep)
Independence Blue Cross is updating the billing code for Belantamab mafodotin-blmf (Blenrep) effective July 1, 2026. The unclassified codes C9399 and J3590 are being replaced with the specific HCPCS code J9053. This change requires billing teams to update their systems to use the new code for all Blenrep claims going forward.
Independence Blue Cross · Effective Jul 1, 2026High impact
08.01.90d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)
Effective 07/01/2026, Independence Blue Cross is replacing two unclassified NOC/HCPCS codes (C9399 and J3590) with a single specific HCPCS code J9062 for Rybrevant Faspro (amivantamab and hyaluronidase-lpuj) subcutaneous injections. Billing teams must update systems to discontinue use of the old codes and transition all claims for this drug to the new J9062 code to avoid claim rejections.
Anthem BCBS · Effective Jul 1, 2026High impact
[New York] Specialty pharmacy updates — July 2026
Anthem Blue Cross and Blue Shield is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria updates effective October 1, 2026. Patients currently receiving Avlayah, Filkri, and Ponlimsi may require prior authorization going forward, and 16 additional oncology and specialty drugs will have revised clinical criteria that may result in coverage denials.
Anthem BCBS · Effective Jul 1, 2026High impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem Blue Cross and Blue Shield in Ohio is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria revisions effective October 1, 2026. Patients currently receiving Avlayah, Filkri, and Ponlimsi without prior authorization will require new authorization requests going forward, and multiple oncology drugs will have revised clinical criteria that may result in coverage denials.
Anthem BCBS · Effective Jul 1, 2026High impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria revisions effective October 1, 2026. Patients currently receiving these medications without prior authorization will require approval going forward, and certain previously covered services may now be deemed not medically necessary under revised clinical criteria.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect HCPCS C9399?

There are 50 tracked policy changes affecting HCPCS C9399, including updates from Aetna, Capital Blue Cross, Anthem BCBS. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS C9399?

Payers that have issued tracked updates for HCPCS C9399 include: Aetna, Capital Blue Cross, Anthem BCBS, Sentara Health Plans, UnitedHealthcare, Medicare/CMS - Transmittals, Independence Blue Cross, Florida Blue, Blue Cross Blue Shield of North Dakota, Arkansas Blue Cross Blue Shield, BCBS Michigan.

How do I get notified when HCPCS C9399 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS C9399. You will get an email when new policy changes reference this code: daily or weekly, your choice, on every plan.

Why do payers change policies for HCPCS C9399?

Payers revise policies for individual billing codes to align with updated clinical guidelines, CMS rule changes, fraud and abuse prevention measures, or network cost-management goals. Changes can affect medical necessity criteria, place-of-service restrictions, bundling rules, or whether a code requires prior authorization.

All billing codes J3590 J3490 99215 99213 99202 99214

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OfficeLink Updates - August 2026 notices and reminders (PDF)

AB2026-11-005 Medical policies

[New York] Specialty pharmacy updates

[Ohio] Specialty pharmacy updates

[Virginia] Specialty pharmacy updates

[Georgia] Specialty pharmacy updates

OfficeLink Updates - November 2026 notices and reminders (PDF)

[New York] Specialty pharmacy precertification list expands

[Ohio] Specialty pharmacy precertification list expands

[Virginia] Specialty pharmacy precertification list expands

Authorization Updates - Effective January 1, 2027

OfficeLink Updates - October 2026 notices and reminders (PDF)

[Ohio] Specialty pharmacy updates — November 2026

Medicare Part B Step Therapy Programs

R13958CP: January 2027 Quarterly Average Sales Price (ASP) Medicare Part B Drug Pricing Files and Revisions to Prior Quarterly Pricing Files

[New York] Specialty pharmacy updates — November 2026

[Virginia] Specialty pharmacy updates — November 2026

[Georgia] Specialty pharmacy updates — November 2026

AB2026-10-005 Medical policies

08.00.46f, Isatuximab-irfc (Sarclisa®, Sarclisa Escena)

Medicare Part B Step Therapy Oct Updates

Provider Administered Drugs – Site of Care

Provider Administered Drugs – Site of Care

AB2026-09-005 Medical policies

Pharmacy Policies Available Online

[New York] Specialty pharmacy updates — July 2026

[Ohio] Specialty pharmacy updates — July 2026

[Virginia] Specialty pharmacy updates — July 2026

[Georgia] Specialty pharmacy updates — July 2026

AB2026-08-005 Medical policies

08.02.49b, Pembrolizumab and berahyaluronidase alfa-pmph (Keytruda QLEX™)

AB2026-07-005 Medical policies

[Virginia] Specialty pharmacy updates for May 2026

[Georgia] Specialty pharmacy updates for May 2026

MA08.063i, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb​ (Poherdy​)

08.01.07l, Pertuzumab (Perjeta®) and related biosimilar pertuzumab-dpzb​ (Poherdy​)

Payment Policy Material Amendment

Pharmacy Policy Updates

HCPCS replacement codes established, effective July 1, 2026

MA00.005at, Experimental/Investigational Services

12.01.01bu, Experimental/Investigational Services

MA08.042l, Ustekinumab for Intravenous Use

MA08.148d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)

08.00.82q, Ustekinumab for Intravenous Infusion

08.01.23k, Interleukin-5 (IL-5) Antagonist (e.g., Cinqair, Exdensur)

08.02.53a, Belantamab mafodotin-blmf (Blenrep)

08.01.90d, Amivantamab-vmjw (Rybrevant®) and Amivantamab and hyaluronidase-lpuj (Rybrevant Faspro™)