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J3490

PAYER POLICY CHANGES

J3490 Insurance Policy Changes

HCPCS J3490 is officially defined as "Unclassified drugs." HCPCS J3490 is referenced in 50 tracked payer policy changes from Aetna, Sentara Health Plans, and 12 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J3490 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.
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.
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.
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.
UnitedHealthcare · Effective Nov 1, 2026High impact
Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw) (for Pennsylvania Only)
UnitedHealthcare Community Plan of Pennsylvania has updated coverage for two thyroid eye disease treatments (Lumvoa and Tepezza) effective November 1, 2026. The policy now covers both drugs under the same clinical criteria, adds new HCPCS billing codes (J3490, J3590), and establishes lifetime dose limits (5 doses for Lumvoa, 8 doses for Tepezza). Billing teams must implement prior authorization requirements and update systems to enforce these new limits.
Harvard Pilgrim Health Care · Effective Oct 1, 2026High impact
Point32Health medical drug program updates
Point32Health is implementing extensive prior authorization requirements for multiple new-to-market drugs and updating criteria for existing drug programs across Harvard Pilgrim and Tufts Health plans, effective October 1, 2026. New drugs including Filkri, Ospomyv/Xbryk, Vykoura, Armlupeg, and Blenrep now require prior authorization/step therapy. Additionally, MassHealth carve-out drugs and Carelon lab codes are adding or updating prior authorization requirements.
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.
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.
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.
Florida Blue · Effective Jul 15, 2026High impact
Updated Categories for Medicare Advantage Part B Step Therapy
Florida Blue Medicare updated its Part B Step Therapy program effective July 15, 2026, reclassifying certain cancer supportive therapy and immune globulin products from preferred to non-preferred (requiring step therapy), while moving a limited number of products to preferred status. Billing teams must update prior authorization requirements and preferred drug lists in their systems to reflect these changes.
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.
Aetna · Effective Jul 1, 2026High impact
OfficeLink Updates - July 2026 notices and reminders (PDF)
Aetna's National Precertification List changes take effect in stages: on July 1, 2026, precertification was removed for Tegsedi and the iui case rate and added for several biosimilars, specialty drugs and hypoglossal nerve neurostimulator procedures, with further changes on August 1, 2026 and October 1, 2026. Effective October 1, 2026, Florida Dual-Eligible Special Needs Plans require precertification for certain home health aide, certified nurse assistant and personal care services. Beginning in 2027, maternity care will be reported as separate services for each phase of care instead of a single global service, and the transition period for remote physiological monitoring members runs through December 31, 2026.
Anthem BCBS · Effective Jun 1, 2026High impact
[New York] Expansion of specialty pharmacy precertification list
Effective June 1, 2026, Anthem Medicare Advantage in New York is expanding its specialty pharmacy precertification requirements to include 9 new Part B drugs and implementing step therapy for Keytruda Qlex and Tecentriq Hybreza. All claims for these medications without proper precertification and step therapy compliance will be deemed ineligible for reimbursement.
Anthem BCBS · Effective Jun 1, 2026High impact
[New York] Specialty pharmacy updates, March 2026
Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Billing teams must update systems to require prior authorization for non-oncology specialty drugs managed by Anthem and oncology drugs managed by Carelon, and enforce quantity limits and step therapy edits on specified medications. Patients currently receiving these medications without prior auth may face coverage changes.
Anthem BCBS · Effective Jun 1, 2026High impact
[Ohio] Expansion of specialty pharmacy precertification list
Effective June 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and implementing step therapy review for specific immunotherapy medications. Billing teams must obtain precertification for these drugs before dispensing and apply step therapy protocols for Keytruda Qlex and Tecentriq Hybreza, except for members already actively receiving the original preferred formulations.
Anthem BCBS · Effective Jun 1, 2026High impact
[Ohio] Specialty pharmacy updates, March 2026
Anthem is implementing new prior authorization requirements, quantity limits, and step therapy restrictions for 8 specialty pharmacy drugs effective June 1, 2026. Billing teams must obtain prior authorization for these medications before service dates and include NDC codes on claims to expedite processing. Patients currently receiving these drugs without authorization will require new prior auth requests going forward.
Anthem BCBS · Effective Jun 1, 2026High impact
[Virginia] Specialty pharmacy updates, March 2026
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 8 specialty pharmacy drugs effective June 1, 2026. Patients currently receiving these medications without prior authorization will require PA requests going forward. Billing teams must identify these drugs by NDC code and Clinical Criteria document number to route claims appropriately.
Anthem BCBS · Effective Jun 1, 2026High impact
[Virginia] Expansion of specialty pharmacy precertification list
Effective June 1, 2026, Anthem Blue Cross Blue Shield Virginia is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and implementing step therapy review for pembrolizumab and atezolizumab variants. Billing teams must obtain precertification for these drugs before claims submission, and step therapy will apply to new patients (not current users). Noncompliance will result in claim denials.
Anthem BCBS · Effective Jun 1, 2026High impact
[Georgia] Specialty pharmacy updates, March 2026
Effective June 1, 2026, Anthem Blue Cross Blue Shield (Georgia) is implementing new prior authorization requirements, quantity limits, and step therapy protocols for 8 specialty pharmacy medications. Billing teams must begin requesting prior authorization for these drugs on all dates of service on or after June 1, 2026, and include NDC codes on claims to expedite processing. Oncology-use prior authorizations will be managed by Carelon Medical Benefits Management rather than Anthem's standard review team.
Alaska Medicaid · Effective May 11, 2026High impact
April 2026 Town Hall Presentation
Alaska Medicaid requires service authorization for the listed intravenous immunoglobulin HCPCS codes, and for J3490 billed with NDC 25357-0024-01 (Epoxia), for dates of service on or after May 11, 2026. Dental code D9248 is no longer covered for dates of service on or after January 1, 2026, and D9244 and D9245 have been turned on as replacements. The next self-audit cycle for Medicaid providers, covering calendar year 2023 or 2024, is due no later than December 31, 2026.
Aetna · Effective May 1, 2026High impact
OfficeLink Updates - May 2026 notices and reminders (PDF)
Aetna has updated their National Precertification List with multiple changes taking effect between May 2026 and January 2027. Several drugs will now require precertification including ustekinumab-srlf, ranibizumab-nuna, and others, while Fulphila will no longer require precertification for Medicare patients.
Anthem BCBS · Effective May 1, 2026High impact
[New York] Specialty pharmacy updates — February 2026
Effective May 1, 2026, Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy drugs across multiple therapeutic areas. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must identify claims for these drugs and ensure prior authorization is obtained before or concurrent with claim submission to avoid denials.
Anthem BCBS · Effective May 1, 2026High impact
[Virginia] Specialty pharmacy updates — February 2026
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 13 specialty pharmacy drugs effective May 1, 2026. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must update systems to request prior authorization for these specialty drugs and include NDC codes on claims to expedite processing.
Anthem BCBS · Effective May 1, 2026High impact
[Ohio] Anthem expands specialty pharmacy precertification list
Effective May 1, 2026, Anthem is expanding its specialty pharmacy precertification list for Medicare Advantage members in Ohio. Ten specialty Part B drugs now require prior authorization, and six denosumab biosimilars plus one aflibercept product require step therapy review before approval. Billing teams must update systems to require precertification for these medications to avoid claim denials.
Aetna · Effective Apr 1, 2026High impact
OfficeLink Updates - January 2026 notices and reminders (PDF)
Aetna is implementing multiple policy changes effective April 1, 2026, including new prior authorization requirements for specialty drugs and procedures, bundling of medication-assisted treatment services, updated coding rules for ventral hernias, and new modifier requirements for reduced/discontinued services.
Aetna · Effective Apr 1, 2026High impact
OfficeLink Updates - February 2026 notices and reminders (PDF)
Aetna is adding precertification requirements for 16 new specialty drugs and medical injectables, with most changes effective April 1, 2026. Additionally, Site of Care requirements will apply to two specific drugs for commercial plans starting April 1, 2026.
Premera Blue Cross · Effective Feb 6, 2026High impact
Medical Policy and Coding Updates - November 2025
Premera HMO plans in Washington have changes from the November 2025 medical policy and coding update. Fifty Routine Test Management policies for laboratory services are effective February 6, 2026, and the notice says they are managed through claims edits for rule-based criteria and are not prior authorization. Other dated items include new medical necessity and prior authorization review for several coded services and Federal Employee Program prior authorization for certain drugs, all listed with an effective date of February 6, 2026.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2026High impact
State and School Employees' Health Insurance Plan - Spravato (esketamine)
Effective January 1, 2026, the State and School Employees' Health Insurance Plan (Mississippi) now classifies Spravato (esketamine) as not medically necessary for treatment-resistant depression and major depressive disorder, citing available alternative treatments. All administration and delivery services related to Spravato are also deemed not medically necessary. The drug is considered investigational for all other conditions.
Blue Cross & Blue Shield of Mississippi · Effective Jan 1, 2026High impact
Nitisinone
Nitisinone requires prior authorization, and samples given to an individual are not considered current or stable therapy. Harliku (nitisinone) and Nityr (nitisinone) are not covered on any BCBSMS Formulary. Nitisinone may be considered medically necessary for hereditary tyrosinemia type 1 used with dietary restriction of tyrosine and phenylalanine, or for alkaptonuria in individuals 18 years of age or older, when the diagnosis is confirmed and the dose is within program quantity limits.
Florida Blue · Effective Jan 1, 2026High impact
Medicare Part B Step Therapy Product Updates
Florida Blue Medicare updated its Part B Step Therapy programs for Medicare Advantage plans, effective January 1, 2026. Multiple drug categories now have new preferred and non-preferred medications, requiring step therapy trials of preferred products before non-preferred drugs can be approved.
WellCare · Effective Jan 1, 2026High impact
[Georgia] Prior Authorization Update for Evolent: Effective January 1, 2026 (PDF)
Beginning January 1, 2026, the procedure codes in this Centene bulletin require prior authorization through Evolent, which manages prior authorizations for Centene in medical oncology, radiation oncology, pediatric and dose optimization, and cardiology. The change applies to all Ambetter (Marketplace), Medicaid and Medicare products offered by Centene. The code table includes anti-emetics, bone metastasis drugs, cancer treatment drugs, and supportive medications such as iron products, ESAs, myeloid growth factors and immune globulins.
Aetna · Effective Nov 1, 2025High impact
OfficeLink Updates - November 2025 notices and reminders (PDF)
Aetna is implementing multiple prior authorization changes for specialty drugs and procedures, removing precertification requirements for artificial insemination procedures, and requiring valid CPT/HCPCS codes for behavioral health services. Key changes take effect at various dates from November 2025 through February 2026.
Florida Blue · Effective Sep 15, 2025High impact
Updated Categories for Medicare Advantage Part B Step Therapy
Florida Blue Medicare updated its Part B Step Therapy program effective September 15, 2025, adding new non-preferred drugs to four categories that now require step therapy and prior authorization. Billing teams must ensure preferred alternatives are tried first or obtain prior authorization for the newly added non-preferred medications.
Harvard Pilgrim Health Care · Effective Aug 1, 2025High impact
Point32Health medical drug program updates
Point32Health has implemented new prior authorization requirements for multiple oncology and specialty drugs across Harvard Pilgrim and Tufts Health plans, effective August 1, 2025 through November 1, 2025. Additionally, CAR-T cell therapies have been updated to remove REMS-only restrictions and clarify immunosuppressive therapy limitations, with new pediatric indications added for certain drugs. A new Parkinson's disease drug (Onapgo) now requires prior authorization effective September 1, 2025.
Aetna · Effective Aug 1, 2025High impact
OfficeLink Updates - August 2025 notices and reminders (PDF)
Aetna is implementing three major changes: a new payment structure for Medicare inpatient stays 1+ midnight that pays faster at observation rates with appeal rights, new CPT code requirements for lesion excisions based on tissue depth, and expanded precertification requirements for multiple specialty drugs including biosimilars.
Aetna · Effective Jul 1, 2025High impact
OfficeLink Updates - April 2025 notices and reminders (PDF)
Aetna updated their National Precertification List with multiple new drug requirements and removed precertification for BRCA genetic testing. Several new specialty drugs now require precertification with staggered effective dates from March through April 2025, and new claim edits will be implemented starting July 1, 2025.
Blue Cross Blue Shield of North Dakota · Identified Oct 24, 2026High impact
Pharmacy Policies Available Online
Blue Cross Blue Shield of North Dakota's October 22, 2026 pharmacy policy update lists Commercial and Medicaid Expansion pharmacy policy changes with several different effective dates, including November 1 and December 1, 2026. Effective December 1, 2026, the intravitreal injection policy adds HCPCS code J3490 for Ranluspec, the portable external infusion pump policy adds codes A4228 and E0788, and the therapeutic radiopharmaceuticals policy for neuroendocrine tumors removes Iobenguane I 131 (A9590) and associated codes 77300, 78804, 96365 and 96374, because the manufacturer withdrew the product from the market. The notice also lists new Medicaid Expansion prior authorization policies for five drugs effective December 1, 2026, and says three Medicaid Expansion policies will be retired on that date.
Blue Cross of Idaho · Identified Sep 29, 2026High impact
PAP271 - Infusion Therapy Guidelines for Non-Home Infusion, Specialty Infusion and Specialty Pharmacy Providers - Added clarification on NDC requirements
Blue Cross of Idaho clarified NDC (National Drug Code) requirements for infusion therapy claims. All medical drug codes now require both an NDC and a narrative description when submitted; claims without NDC codes will be denied as corrected claims. This reinforces existing policy but adds explicit emphasis on the October 2025 update referencing Medical Policy MP 5.01.502 for non-covered drugs.
Premera Blue Cross · Identified Sep 3, 2026High impact
Medical Policy and Coding Updates - September 2026
Premera's September 2026 medical policy and coding update adds new review requirements for several services on different dates. Negative pressure wound therapy codes 97605, 97606, 97607 and 97608 now require review for medical necessity and prior authorization effective September 4, 2026, and immune checkpoint inhibitors now require review for medical necessity and prior authorization effective September 1, 2026. Endovascular stent grafts for abdominal aortic aneurysms (codes 34717 and 34718) will require medical necessity and prior authorization review effective November 6, 2026, and Carelon's radiation oncology guideline states radiation therapy is considered not medically necessary for select conditions, including osteoarthritis, neovascular age-related macular degeneration and refractory ventricular tachycardia, for dates of service on and after November 15, 2026.
Aetna · Identified Jun 19, 2026High impact
OfficeLink Updates - July 2025 notices and reminders (PDF)
Precertification was added for denosumab products (denosumab-dssb, Osenvelt, Stoboclo, Ospomyv, Xbryk) with J3490, J3590 and C9399 effective June 18, 2025, and for ustekinumab products and Avtozma (tocilizumab-anoh) with the same codes effective June 23, 2025, where Avtozma precertification includes the site of care. Encelto (revakinagene taroretcel-lwey, J3490, J3590, C9399) requires precertification effective July 15, 2025. Effective July 1, 2025, precertification is no longer required for electric scooters (E1230), orthognathic surgery codes, and surgical management of the temporomandibular joint (D7830, D7871), and for Medicare plans only, hyperbaric oxygen therapy (99183, G0277). Starting October 1, 2025, initial prior authorization for certain immune checkpoint inhibitors given in an outpatient hospital site is approved for 90 days for patients new to therapy after October 1, and this change applies only to new approvals.
Aetna · Identified Jun 19, 2026High impact
OfficeLink Updates - October 2025 notices and reminders (PDF)
Several precertification and coverage changes in this October 2025 notice have already taken effect. Emrelis and Zusduri require precertification as of September 1, 2025, and Zevaskyn and Imaavy require it for Medicare, with site-of-care precertification added for commercial plans. Botox, Xeomin, Procrit, Aranesp and Mircera are no longer precertified for Medicare only. Jobevne requires precertification as of October 1, 2025. Beizray (J9174) and partial excision of a posterior vertebral component (22102 and 22103) require precertification as of January 1, 2026. Effective January 1, 2026, Medicare Advantage plans in New Jersey, New York, Pennsylvania and West Virginia require EviCore pre-approval for inpatient rehabilitation, skilled nursing and listed home health codes, and Avastin, Alymsys, Mvasi, Vegzelma, Zirabev and Krystexxa are added to the commercial Site of Care for Specialty Drug Administration policy. Codes A6530 to A6534, A6539, A6545 and A6549 are non-covered compression supplies for commercial plans effective January 1, 2026. Effective November 1, 2025, CPT codes 11400-11471 and 11600-11646 are used for excision of cutaneous lesions and superficial subcutaneous lesions of cutaneous origin. Beginning December 1, 2025, CPAP devices and supplies are reimbursed only when positive airway pressure therapy is documented with adherence codes G8851, G8854 and G8855.
Aetna · Identified Jun 19, 2026High impact
OfficeLink Updates - April 2026 notices and reminders (PDF)
This April 2026 notice covers several changes that have all passed their stated dates. Effective March 1, 2026, Remote Physiologic Monitoring (CPT 99453-99458) is covered only for heart failure, hypertension or diabetes, with an FDA-approved or FDA-cleared device that transmits data automatically, data used to adjust treatment, and documented member consent. Effective April 1, 2026, laminectomy codes performed as part of the access for spinal osteotomy codes 22212 and 22214 are not reimbursed separately on the same date of service. Effective July 1, 2026, reconstructive codes 15733-15738 and 14000-14302 are denied as incidental when billed on the same date of service as breast surgery (19300-19396) or digestive system surgery (40490-49999) codes by different providers. Commercial drug lists and the Combined Benefit Management drug list were updated on July 1, 2026, and several drugs were added to precertification lists with dates from March 1, 2026 through July 1, 2026.

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FREQUENTLY ASKED QUESTIONS

What insurance policy changes affect HCPCS J3490?

There are 50 tracked policy changes affecting HCPCS J3490, including updates from Aetna, Sentara Health Plans, UnitedHealthcare. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J3490?

Payers that have issued tracked updates for HCPCS J3490 include: Aetna, Sentara Health Plans, UnitedHealthcare, Harvard Pilgrim Health Care, Florida Blue, Anthem BCBS, Capital Blue Cross, BCBS Michigan, Alaska Medicaid, Premera Blue Cross, Blue Cross & Blue Shield of Mississippi, WellCare, Blue Cross Blue Shield of North Dakota, Blue Cross of Idaho.

How do I get notified when HCPCS J3490 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J3490. 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 J3490?

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 C9399 99215 99213 99202 99214

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OfficeLink Updates - August 2026 notices and reminders (PDF)

OfficeLink Updates - November 2026 notices and reminders (PDF)

Authorization Updates - Effective January 1, 2027

OfficeLink Updates - October 2026 notices and reminders (PDF)

Medicare Part B Step Therapy Programs

Lumvoa ™ (Veligrotug-Vvze) and Tepezza® (Teprotumumab-Trbw) (for Pennsylvania Only)

Point32Health medical drug program updates

Medicare Part B Step Therapy Oct Updates

Provider Administered Drugs – Site of Care

Provider Administered Drugs – Site of Care

[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

[Virginia] Specialty pharmacy updates for May 2026

[Georgia] Specialty pharmacy updates for May 2026

Updated Categories for Medicare Advantage Part B Step Therapy

HCPCS replacement codes established, effective July 1, 2026

OfficeLink Updates - July 2026 notices and reminders (PDF)

[New York] Expansion of specialty pharmacy precertification list

[New York] Specialty pharmacy updates, March 2026

[Ohio] Expansion of specialty pharmacy precertification list

[Ohio] Specialty pharmacy updates, March 2026

[Virginia] Specialty pharmacy updates, March 2026

[Virginia] Expansion of specialty pharmacy precertification list

[Georgia] Specialty pharmacy updates, March 2026

April 2026 Town Hall Presentation

OfficeLink Updates - May 2026 notices and reminders (PDF)

[New York] Specialty pharmacy updates — February 2026

[Virginia] Specialty pharmacy updates — February 2026

[Ohio] Anthem expands specialty pharmacy precertification list

OfficeLink Updates - January 2026 notices and reminders (PDF)

OfficeLink Updates - February 2026 notices and reminders (PDF)

Medical Policy and Coding Updates - November 2025

State and School Employees' Health Insurance Plan - Spravato (esketamine)

Nitisinone

Medicare Part B Step Therapy Product Updates

[Georgia] Prior Authorization Update for Evolent: Effective January 1, 2026 (PDF)

OfficeLink Updates - November 2025 notices and reminders (PDF)

Updated Categories for Medicare Advantage Part B Step Therapy

Point32Health medical drug program updates

OfficeLink Updates - August 2025 notices and reminders (PDF)

OfficeLink Updates - April 2025 notices and reminders (PDF)

Pharmacy Policies Available Online

PAP271 - Infusion Therapy Guidelines for Non-Home Infusion, Specialty Infusion and Specialty Pharmacy Providers - Added clarification on NDC requirements

Medical Policy and Coding Updates - September 2026

OfficeLink Updates - July 2025 notices and reminders (PDF)

OfficeLink Updates - October 2025 notices and reminders (PDF)

OfficeLink Updates - April 2026 notices and reminders (PDF)

What insurance policy changes affect HCPCS J3490?

Which payers have updated policy for HCPCS J3490?

How do I get notified when HCPCS J3490 policy changes?

Why do payers change policies for HCPCS J3490?