CommercialPrior AuthHigh impact
AB2026-08-005 Medical policies
Capital Blue Cross·Oncology, Hematology, Pediatrics +6 more·Medical Policy
Effective date
Sep 1, 2026
We identified it
Jul 31, 2026
Summary
Capital Blue Cross has updated medical policies effective September 1 and October 1, 2026, affecting injectable specialty drugs, medical devices, and surgical procedures. Key changes include new prior authorization requirements for four specialty injectable drugs (Otarmeni, Wainua, Nufymco, and Evdi), revised step therapy requirements for multiple oncology and hematology medications, updated coverage criteria for cochlear implants (age lowered to 7 months), and reorganization of prostate cancer treatment policies. Multiple surgical and diagnostic procedure codes have been added, removed, or reclassified.
Action Required
By August 15, 2026: 1) Billing team must update prior authorization requirements in billing system for new injectable drugs: J3590, C9399 (Otarmeni); J3490, C9399 (Wainua); Q5168 (Nufymco biosimilar); J9999 (Evdi/Trabectedin). All requests must be submitted via Prime MPS GatewayPA Portal at http://www.GatewayPA.com or by phone 800.424.1710 for Commercial plans. 2) Update step therapy logic for all revised medications effective 10/1/2026 (Denosumab, Tocilizumab, Long-Acting G-CSF, Gemcitabine, Inlexzo, Kyxata, and all Factor/Coagulation products). 3) For Cochlear Implant procedures (MP 1.023), update authorization criteria to allow age 7 months (previously 9 months). 4) Remove prior authorization requirement for CPT 92520 (Rhinomanometry). 5) Reorganize prostate cancer procedure codes: move CPT 0950T to MP 4.002; move CPT 55874 to new MP 4.054; add CPT C2596, 52597, 53854, 55899 to new policy MP 4.053. 6) Stop billing retired policy 1.012 (Abdominoplasty/Panniculectomy) and route all requests through MP 1.004 or InterQual. 7) Providers should consult updated policies on Draft Medical Policies page before submitting claims. Failure to obtain required prior authorization will result in claim denials.