← Back to list
AB2026-11-005 Medical policies
Act
by Dec 1, 2026
Effective date
Dec 1, 2026
Identified
Oct 31, 2026
Summary
Capital Blue Cross administrative bulletin 2026-11-005, dated November 1, 2026, lists medical policy updates with an effective date of December 1, 2026 unless otherwise indicated. Changes effective December 1, 2026 include added procedure codes in the Durable Medical Equipment policy and new preauthorization requirements for several Prime Therapeutics injectables. Many other changes take effect January 1, 2027, including EviCore's Clinical Guidelines for Lab Management Program, Version 1.0.2027, updated Evolent radiology and radiation oncology guidelines, and updated TurningPoint musculoskeletal and cardiology policies.
Get alerts when payers change rules like this one
We check Capital Blue Cross and other payers every day and email you when a change matches your specialty and state.
Get Capital Blue Cross alertsPolicy Monitoring is free. No card required.
What to do
by Dec 1, 2026 · 4 steps
01Get preauthorization for the injectables the source says now require it, and submit requests through the Prime MPS GatewayPA Portal.
02These include J9999 and C9399 for Revtorpyk, J3590 and C9399 for Tregzi and Lumvoa, J3590 for Lytenava, and Q5154 for Omlyclo.
03Check the Capital Blue Cross Single Source Preauthorization List on the CapBlueCross.com provider web page for the full list of codes that require preauthorization.
04Changes to the EviCore, Evolent and TurningPoint guidelines take effect January 1, 2027, so read the bulletin at the source link for those details.
Codes mentioned
D04.111D04.112D04.11A6515A6516A6517A6518A6519A6540A6611E0465E0466E0467E0468E1035E1036K0739K0900E0221L5827L5859J9999C9399J3590Q5154Q5151Q5152Q5156Q5135Q5167Q5162J2361
Original notice
AB2026-11-005 Medical policies
capbluecross.com · Always check the source before changing claims.
Related changes
See all Capital Blue Cross changes →AB2026-11-002 Medicare onlyHighEffective Jan 1, 2027 · Provider NewsAB2026-09-005 Medical policiesHighEffective Oct 1, 2026 · Medical PolicyAB2026-08-005 Medical policiesHighEffective Sep 1, 2026 · Medical PolicyAB2026-04-004 Medical policiesHighEffective May 1, 2026 · Medical PolicyBrowse every Capital Blue Cross change in the policy list
Related policy hubs
Capital Blue Cross policiesCardiologyDermatologyGeneticsOrthopedicsOncologyOphthalmologyPathologyPharmacyRadiation OncologyRadiologyCode D04.111Code D04.112Code D04.11Code A6515Code A6516Code A6517Code A6518Code A6519Code A6540Code A6611Code E0465Code E0466Code E0467Code E0468Code E1035Code E1036Code K0739Code K0900Code E0221Code L5827Code L5859Code J9999Code C9399Code J3590Code Q5154Code Q5151Code Q5152Code Q5156Code Q5135Code Q5167Code Q5162Code J2361