Medicare AdvantagePrior AuthMedium impact
AB2026-03-002 Medicare only
Capital Blue Cross·Oncology, Pulmonology, Ophthalmology +1 more·Provider News
Effective date
May 1, 2026
We identified it
Jun 20, 2026
Summary
Capital Blue Cross updated Prime Therapeutics clinical guidelines for Medicare Advantage plans, adding new HCPCS codes to step therapy requirements and clarifying the 90-day Continuity of Care rule that waives prior authorization for new Medicare Advantage members during their transition period.
Action Required
By April 20, 2026: Billing team must update step therapy protocols for new HCPCS codes Q5160, J9361, Q5155, Q5153, and J2182 for Medicare Advantage members. Remove J2356 from preferred agent lists for Asthma/COPD treatments. Update prior authorization workflows to recognize 90-day Continuity of Care period for new Medicare Advantage members. Train staff to check member plan start dates and submit authorization requests 10 days before COC period expires.