CommercialPrior AuthHigh impact
AB2026-07-005 Medical policies
Capital Blue Cross·Oncology, Hematology, Ophthalmology +10 more·Medical Policy
Effective date
Aug 1, 2026
We identified it
Jul 1, 2026
Summary
Capital Blue Cross has implemented major updates to medical specialty injectable policies (delegated to Prime MPS for Commercial plans) and revised multiple non-injectable medical policies effective August 1-September 1, 2026. Two new drugs (Kresladi and Avlayah) now require prior authorization, multiple biosimilars require new prior auth (Denosumab, Neulasta), and over 40 existing injectable drugs have revised policies. Additionally, several procedural policies have been restructured with new codes and changed medical necessity determinations.
Action Required
By July 15, 2026: (1) BILLING TEAM: Update billing software to require prior authorization for J3590/C9399 (Kresladi), J3590 (Avlayah), Q5165 (Oziltus), Q5166 (Osyvrti/Jubereq), Q5171 (Boncresa), and Q5169 (Armlupeg) effective 8/1/2026. Submit all prior auth requests for these injectable drugs through Prime MPS GatewayPA Portal (http://www.GatewayPA.com) or call 800-424-1710 for urgent requests. (2) PROVIDERS AND CLINICAL STAFF: Review updated clinical criteria for all 40+ revised injectable drugs (effective 9/1/2026); full details available at Prime MPS portal or Capital's Medicare policies page. (3) BILLING TEAM: Remove procedure codes 65760, 65765, 65771, 65710, 65730, 65750, 65755, 65756, 65757, 65767 from billing workflows as they are exclusions; update systems to reflect new biofeedback policy structure (codes 90875, 90876, 90901, 90912, 90913, E0746 now map to specific policies MP 2.398-2.401). (4) FRONT DESK/PRIOR AUTH STAFF: Establish tracking for policies with changed effective dates (8/1/2026 vs 9/1/2026). (5) ALL STAFF: Communicate with patients enrolled in Commercial plans that prior authorization periods for some drugs have changed per individual drug policies. Consequence of inaction: Claims for new drugs without prior authorization will be denied; claims using removed codes will be denied as not covered.