Boletín administrativo: 2026-03-002 Medicare only
Date: March 1, 2026
Los temas tratados en este boletín administrativo aplican a:
Proveedores profesionales y de centros
- Annual review and updates to Prime Therapeutics™ guidelines.
- Prime Therapeutics (Prime) – Continuity of Care.
A menos que se indique lo contrario, si tiene alguna pregunta relacionada con la información de este boletín, comuníquese con su asesor para proveedores o visite capbluecross.com/wps/portal/cap/provider/pec-look-up e ingrese su NPI o ID tributaria para identificar su punto de contacto designado en Capital Blue Cross.
Proveedores profesionales y de centros
Annual review and updates to Prime Therapeutics™ guidelines
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Tradicional e Integral
- Medicare Advantage PPO
KEY POINT: Updates have been made to Capital Blue Cross' clinical guidelines by our vendor, Prime Therapeutics.
Please share these changes with your office staff, as they could impact step therapy authorization requests effective May 1, 2026, for our Medicare Advantage members.
Prime Therapeutics Approved Clinical Guidelines, Effective May 1, 2026 |
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Número de la política |
Nombre de la política |
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Capital BC Medicare Part B ST |
Capital Blue Cross Step Therapy Requirements for Medicare Outpatient (Part B) Medications |
New codes added to existing categories:
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Administrative changes:
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New permanent codes assigned to existing categories: Q5155 and Q5153 (Ophthalmic Injections) |
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New code added to preferred agents: J2182 (Asthma/COPD) |
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Code removed from preferred agents: J2356 (Asthma/COPD) |
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Prime Therapeutics (Prime) – Continuity of Care
- CHIP
- EPO
- FEP PPO
- HMO
- Medicare Advantage HMO
- POS
- PPO
- Tradicional e Integral
- Medicare Advantage PPO
KEY POINT: Prime Therapeutics (Prime) applies the following process to align with the CMS 90-day Continuity of Care (COC) rule when managing Capital's preauthorization of specialty medications routinely covered under a patient's medical benefit.
Ciertos medicamentos médicos inyectables requieren autorización previa para ser elegibles para la cobertura del beneficio médico. These medications are maintained on the Capital Blue Cross Single source preauthorization list. located on Capital's provider web page, and may be updated from time to time. Preauthorization may be obtained directly through Prime via www.GatewayPa.com.
Continuity of Care:
Medicare Advantage plans must provide a 90-day transition period for members switching plans, during which prior authorization is not required for active treatments. To align with this rule, Prime allows members to continue receiving their ongoing treatment without preauthorization requirements through the following process:
- When an authorization request for a member who may be in this 90-day transition period is received, Prime's intake team first checks the eligibility start dates for these members.
- Providers are informed that the member is currently within the 90-day Continuity of Care period and that no authorization is required at this time.
- Prime also requests that providers submit an authorization for the member at least ten (10) calendar days before the end of the current validity period.
Note: The plan start date is not the date the member started with Capital or with Medicare. It's the date they went live with their most current Medicare Advantage plan.
- Example: If the member was on a Capital Medicare Advantage plan last year, but switched to a different Capital Medicare Advantage plan on January 1, 2026, the member would fall into this 90-day COC window because they have a new plan.