Medicare AdvantageCoverageHigh impact
MA08.190, Chimeric Antigen Receptor T-cell (CAR-T) Therapy: Carvykti® and Abecma®
Independence Blue Cross·Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Feb 9, 2026
We identified it
Jun 19, 2026
Summary
Independence Blue Cross Medicare Advantage has published a new policy (MA08.190) effective 02/09/2026 that consolidates CAR-T therapy coverage for two drugs: Carvykti® (ciltacabtagene autoleucel) and Abecma® (idecabtagene vicleucel). This policy supersedes the previous policy 08.01.43q and now includes expanded indications for POEMS, MIDD, and MGRS in addition to relapsed/refractory multiple myeloma. Billing teams must update systems to recognize the new policy number and ensure claims comply with the updated medical necessity criteria, including prior treatment requirements and organ function assessments.
Action Required
By 02/09/2026: Billing team must update all systems to recognize new policy number MA08.190 as the authoritative CAR-T guidance, replacing 08.01.43q. Update prior authorization workflows to require documentation of: (1) one prior line of therapy including proteasome inhibitor AND immunomodulatory agent with lenalidomide refractoriness, OR three prior lines of therapy; (2) no prior BCMA-targeted therapy (belantamab mafodotin, teclistamab, Abecma for Carvykti requests); (3) organ/bone marrow function parameters (ECOG 0-1, LVEF ≥45%, eGFR ≥60, ALT ≤5x ULN, bilirubin ≤2.0 mg/dL, platelets ≥50,000/mm3, hemoglobin >8.0 g/dL); (4) no active systemic infection, CNS disease, or prior CAR-T/gene therapy; and (5) patient age ≥18 at infusion. Billing team must verify HCPCS codes Q2055 (Abecma) and Q2056 (Carvykti) are linked to correct CPT 38228 (administration). Update claim denial logic to reject requests missing required prior treatment documentation. Notify providers that CPT codes 38225, 38226, 38227 are bundled/not separately reimbursable. Failure to implement new medical necessity criteria will result in claim denials.