Summary
Capital Blue Cross is implementing significant updates to Medicare Advantage plans effective January 1, 2027, including plan county changes, revised medical and pharmacy benefits, elimination of OTC hearing aid coverage, and new clinical guidelines. Additionally, new prior authorization requirements for specific oncology drugs (Bortezomib and Pemetrexed codes) take effect December 1, 2026.
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What to do
Action · 8 steps
01REQUIREMENTS: By November 1, 2026: Billing team must update billing system to require prior authorization for all Bortezomib codes (J9041, J9049, J9051, J9054) and Pemetrexed codes (J9305, J9294, J9296, J9297, J9314, J9322, J9323, J9292, J9304, J9324) for Capital Blue Cross Medicare Advantage members.
02Update clinical documentation templates to reflect new preferred/non-preferred designations per Prime Therapeutics guidelines.
03By December 15, 2026: Billing staff must verify member county of residence for all Medicare Advantage claims to confirm plan availability and correct cost-sharing amounts (especially for members in Northampton, Schuylkill, Adams, Franklin, and York counties).
04By January 1, 2027: Implement billing edits for new lab service copay structure ($0 copay for independent lab processing, $20 copay for outpatient facility lab processing, $100 copay for genetic testing).
05Update copay references in billing system and patient responsibility calculations.
06Update diabetic supply guidance to reflect Contour preferred brand at 0% coinsurance and OneTouch at 50% coinsurance for PPO plans.
07Ensure Tier 4 drug claims limit to 30-day supply maximum with no extended fills.
08Consequences: Claims submitted without required prior authorization will be denied; incorrect cost-sharing will result in claim adjudication errors and member billing issues; failure to update diabetic supply preferences may result in claim denials for non-preferred brands on HMO plans.
Codes mentioned
J9041J9049J9051J9054J9305J9294J9296J9297J9314J9322J9323J9292J9304J9324J9033J9034J9036
Original notice
AB2026-10-002 Medicare only
capbluecross.com · Always check the source before changing claims.