CommercialPrior AuthHigh impact
AB2026-02-003 Medical policies
Capital Blue Cross·Oncology, Neurology, Dermatology +5 more·Medical Policy
Effective date
Mar 1, 2026
We identified it
Jun 20, 2026
Summary
Capital Blue Cross has updated multiple medical policies effective March 1, 2026 and April 1, 2026, including new prior authorization requirements for medical specialty injectables (delegated to Prime MPS), new PA requirement for Blenrep drug (J9999 code), and revised criteria for numerous injectable medications, medical devices, and diagnostic procedures. Medical specialty injectable PA requests must now be submitted through Prime MPS GatewayPA Portal instead of Capital Blue Cross directly.
Action Required
By March 1, 2026: Update billing workflows to submit all medical specialty injectable prior authorization requests through Prime MPS GatewayPA Portal at http://www.GatewayPA.com instead of Capital Blue Cross. By April 1, 2026: Update billing system to require prior authorization for J9999 (Blenrep), remove PA requirements for knee brace codes L1834, L1840, L1846, and add PA requirements for gender affirming surgery codes 54125, 55970, 55980, 56805, 57110, 57292, 57335. Review all revised injectable medication policies for updated clinical criteria. For urgent PA requests, use Prime MPS phone (800.424.1710) or fax (888.656.6671).