J9037 Insurance Policy Changes

HCPCS J9037 is officially defined as "Injection, belantamab mafodotin-blmf, 0.5 mg." HCPCS J9037 is referenced in 6 tracked payer policy changes from Harvard Pilgrim Health Care, Blue Cross Blue Shield of North Dakota, and 4 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for HCPCS J9037 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.

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.
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.
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.
Arkansas Blue Cross Blue Shield · Effective Dec 15, 2025Medium impact
Policy Criteria Changes
Arkansas Blue Cross updated coverage criteria for Tislelizumab-jsgr (Tevimbra) to include FDA-labeled gastric cancer indication and revised off-label uses. Belantamab mafodotin-blmf (Blenrep) policy will be archived as HCPCS code J9037 becomes inactive March 31, 2025.
Aetna · Identified Oct 23, 2026Medium impact
Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging (CPB 0749, reviewed 2026-10-21)
Aetna considers anterior segment optical coherence tomography (OCT) experimental, investigational, or unproven for all indications, including detection of glaucoma, evaluation of conjunctival hyperemia and quantification of corneal haziness, because its clinical value has not been established. Anterior segment imaging with the Pentacam, scanning laser ophthalmoscopy (SLO) and scanning laser polarimetry (SLP) is considered experimental, investigational, or unproven because of insufficient evidence of its effectiveness. CPT code 92132 is not covered for the indications listed in the policy, and Aetna members may not be eligible for Pentacam anterior segment imaging for refractive eye surgeries such as LASIK or laser eye surgery.
Michigan Medicaid - MDHHS · Identified Jun 20, 2026Medium impact
MSA 21-18
MDHHS added, discontinued and re-covered several HCPCS and CPT codes in the July 2021 update to the Medicaid Provider Manual, with dates ranging from February 9, 2021 to April 16, 2021. Prior authorization was discontinued for 81510, 81511 and 81512 effective March 31, 2021, and coverage for M0239 and Q0239 was discontinued effective April 16, 2021 after the FDA revoked emergency use authorization for those codes. The update also set billing rules for MOMS claims, dental incomplete procedures, orthodontic treatment, diagnosis reporting and portable x-ray transportation.

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REFERENCE DATA

Payers with rules3

Payers requiring prior auth3

Centene · Effective December 31, 2025
Prior authorization required
Sunshine Health Title XIX, Title XXI, Managed Medical Assistance CMS-0057-F prior authorization requirements
Fidelis Care · Effective December 31, 2025
Prior authorization required
Fidelis Care CMS-0057-F prior authorization requirements

FREQUENTLY ASKED QUESTIONS

Does AmeriHealth Caritas require prior authorization for J9037?

AmeriHealth Caritas lists J9037 on AmeriHealth Caritas Louisiana prior authorization service list for medicaid managed plans. Verify with the payer before scheduling.

Does Centene require prior authorization for J9037?

Centene lists J9037 on Sunshine Health Title XIX, Title XXI, Managed Medical Assistance CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

Does Fidelis Care require prior authorization for J9037?

Fidelis Care lists J9037 on Fidelis Care CMS-0057-F prior authorization requirements for medicaid managed plans (list dated December 31, 2025). Verify with the payer before scheduling.

What insurance policy changes affect HCPCS J9037?

There are 6 tracked policy changes affecting HCPCS J9037, including updates from Harvard Pilgrim Health Care, Blue Cross Blue Shield of North Dakota, WellCare. Each change may modify coverage criteria, reimbursement rates, or prior-authorization requirements.

Which payers have updated policy for HCPCS J9037?

Payers that have issued tracked updates for HCPCS J9037 include: Harvard Pilgrim Health Care, Blue Cross Blue Shield of North Dakota, WellCare, Arkansas Blue Cross Blue Shield, Aetna, Michigan Medicaid - MDHHS.

How do I get notified when HCPCS J9037 policy changes?

Create a free account at PolicyChanges.app and save a search filtered to HCPCS J9037. 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 J9037?

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.

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Prior authorization lists, coverage criteria, NCCI edits and Medicare coverage articles for J9037 in one place.

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All billing codes J3590 C9399 J3490 99215 99213 99202

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Point32Health medical drug program updates

Pharmacy Policy Updates

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

Policy Criteria Changes

Anterior Segment Scanning Computerized Ophthalmic Diagnostic Imaging (CPB 0749, reviewed 2026-10-21)

MSA 21-18

Prior authorization required