CommercialPrior AuthHigh impact
AB2026-01-003 Medical policies
Capital Blue Cross·Oncology, Hematology, Rheumatology +8 more·Medical Policy
Effective date
Mar 1, 2026
We identified it
Jun 20, 2026
Summary
Capital Blue Cross is implementing new prior authorization requirements for multiple specialty injectable medications and biosimilars, including new drugs Keytruda Qlex and Grafapex, plus updating medical policies for numerous existing medications. Several procedure codes will no longer require prior authorization, and some medical policies are being retired.
Action Required
By March 1, 2026: Billing team must update prior authorization requirements for new specialty injectable drugs Keytruda Qlex (J9999) and Grafapex (J0614), plus new biosimilars for aflibercept, denosumab, IVIG, and ustekinumab. Submit prior authorization requests through Prime MPS GatewayPA Portal at GatewayPA.com or by phone 800.424.1710. Update billing system to remove prior auth requirements for procedure code 48556 (kidney/pancreas transplants). Review all revised medical injectable policies for updated clinical criteria. Some changes effective February 1, 2026 - update encounter forms and billing workflows immediately.