CommercialPrior AuthHigh impact
AB2026-09-005 Medical policies
Capital Blue Cross·Oncology, Rheumatology, Allergy & Immunology +9 more·Medical Policy
Effective date
Oct 1, 2026
We identified it
Sep 1, 2026
Summary
Capital Blue Cross has updated 50+ medical specialty injectable policies and several general medical policies effective October 1 and November 1, 2026. New prior authorization requirements apply to Decnupaz (J9999, C9399) and new biosimilars Filkri and Immgolis Intri. Medical specialty injectable policies have been delegated to Prime Therapeutics (MPS) with updated clinical criteria and a new online submission portal (GatewayPA). Billing teams must identify affected injectable medications in their patient population and implement new prior authorization workflows.
Action Required
By September 15, 2026: Billing team must (1) Register for and test access to Prime MPS GatewayPA Portal (http://www.GatewayPA.com) and select 'Capital Blue Cross' under Clinical Guidelines; (2) Update billing system to require prior authorization for Decnupaz (J9999, C9399), Filkri (J3590), and Immgolis Intri (J3590) effective October 1, 2026; (3) Create internal checklist of all 50+ revised injectable medications and identify which are commonly prescribed by your practice; (4) Train billing and clinical staff on new PA submission process via GatewayPA Portal (or phone 800-424-1710 / fax 888-656-6671 for non-online requests); (5) Update encounter forms and EMR alerts to flag these drugs for PA requirement. By November 1, 2026: Implement prior authorization requirements for all remaining revised injectable medications listed in policy table. Update TENS/NMES billing (procedure codes A4556, A4558, A4630, A4595) per revised MP 6.020 and MP 6.051 guidelines—note that A4558 and A4630 now require investigational status documentation. By October 1, 2026: Retire Step Therapy policy MP 2.373 from billing workflows. Failure to obtain required prior authorization will result in claim denials.