Summary
Capital Blue Cross updated its medical policies, with most changes effective 9/1/2026 or 10/1/2026, and several policies were retired effective 9/1/2026. Capital has delegated medical specialty injectable policies to Prime Medical Pharmacy Solutions (MPS), which revised the Commercial policies to be more medication-specific with updated clinical criteria, and several drug policies now require prior authorization for new products or add new step therapy requirements effective 10/1/2026. Other changes include a cochlear implant age change from 9 months to 7 months, added canthoplasty and canthopexy criteria in the cosmetic and reconstructive surgery policy, and new policies for transurethral water vapor thermal therapy and aquablation and for hydrogel spacer use during radiotherapy for prostate cancer.
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What to do
Action · 14 steps
01Already effective 9/1/2026: Get prior authorization for Otarmeni (J3590 and C9399), Wainua (J3490 and C9399), the Nufymco ranibizumab biosimilar (Q5168), and the new trabectedin product Evdi (J9999), because these now require prior authorization.
02Already effective 10/1/2026: Review the updated policies for denosumab, tocilizumab, long-acting granulocyte colony stimulating factors, gemcitabine, Inlexzo and Kyxata, which have new step therapy requirements, and for the other revised drug policies in the table, using the updated policy for details.
03Prior authorization periods have changed for some drugs, so check the individual drug medical policy for the length of authorization.
04Submit prior authorization requests for these injectable policies online through the Prime MPS GatewayPA Portal at GatewayPA.com under Capital Blue Cross, under Clinical Guidelines.
05For urgent or expedited requests, call Prime.
06If the request cannot be performed online, Prime accepts requests by phone at 800.424.1710 or fax at 888.656.6671.
07Medicare medical injectable policies are on Capital's Medicare medical policies page under the Medical Drugs, Biologics, and Diabetes Supplies dropdown.
08Already effective 9/1/2026: Procedure code 65785 no longer requires prior authorization, and procedure codes 21431, 21432, 21433, 21435 and 21436 no longer require prior authorization because orthognathic surgery criteria are now managed through InterQual; the other orthognathic procedure codes listed in that policy still require prior authorization.
09The blepharoplasty, brow ptosis and reconstructive eyelid surgery policy MP 1.003 is retired, with codes 21280, 21282 and 67950 moving to MP 1.004 and the other listed codes still managed by InterQual.
10Pectus excavatum, rhinoplasty and septoplasty coding was removed from the cosmetic policy and still requires prior authorization with InterQual criteria.
11Procedure code 92520 was removed from the rhinomanometry policy.
12Procedure code 0950T moved to MP 4.002, code 55874 moved to the new hydrogel spacer policy, and codes C2596, 52597, 53854 and 55899 were added to the water vapor and aquablation policy MP 4.053.
13Thermography MA 5.017 is retired, so refer to the National Coverage Determination.
14Because the dates above have passed, check the current applicability of each policy on the Draft medical policies page in the Provider Library before billing these services.
Codes mentioned
J3590C9399J3490Q5168J999921280212826795021740217422174330400304103042030430304353045030460305209252065785214312143221433214352143621125211272114121142211432114521146211472115021151211552115921160211882119321194211952119621198211992120621208212092121021215212442124521246212472129915820158211582215823679006790167902679036790467906679086790969711C259652597538545589955874
Original notice
AB2026-08-005 Medical policies
capbluecross.com · Always check the source before changing claims.
Related changes
See all Capital Blue Cross changes →AB2026-11-005 Medical policiesHighEffective Dec 1, 2026 · Medical PolicyAB2026-09-005 Medical policiesHighEffective Oct 1, 2026 · Medical PolicyAB2026-04-004 Medical policiesHighEffective May 1, 2026 · Medical PolicyAB2026-10-005 Medical policiesHighEffective Nov 1, 2026 · Medical PolicyBrowse every Capital Blue Cross change in the policy list
Related policy hubs
Capital Blue Cross policiesOncologyHematologyOphthalmologyRheumatologyNeurologyEndocrinologyDermatologyUrologyPlastic SurgeryENT (Ear, Nose & Throat)AudiologyOral & Maxillofacial SurgeryPharmacyCode J3590Code C9399Code J3490Code Q5168Code J9999Code 21280Code 21282Code 67950Code 21740Code 21742Code 21743Code 30400Code 30410Code 30420Code 30430Code 30435Code 30450Code 30460Code 30520Code 92520Code 65785Code 21431Code 21432Code 21433Code 21435Code 21436Code 21125Code 21127Code 21141Code 21142Code 21143Code 21145Code 21146Code 21147Code 21150Code 21151Code 21155Code 21159Code 21160Code 21188Code 21193Code 21194Code 21195Code 21196Code 21198Code 21199Code 21206Code 21208Code 21209Code 21210Code 21215Code 21244Code 21245Code 21246Code 21247Code 21299Code 15820Code 15821Code 15822Code 15823Code 67900Code 67901Code 67902Code 67903Code 67904Code 67906Code 67908Code 67909Code 69711Code C2596Code 52597Code 53854Code 55899Code 55874