Effective Date: July 1, 2026

Health Plans Affected: Advantage MD, Employer Health Programs (EHP), Priority Partners, US Family Health Plan (USFHP)

Type of Change: New Codes and Authorization Requirements Status

Explanation of Change: 

Please note additional authorization requirements for quarterly new codes listed below, effective July 1, 2026. 

Key: NPA=No Prior Authorization Required; NC=Not Covered

• A9574 - Injection, ferumoxytol, 1 mg; NPA
• C1609 - Vertebral device, motion-preserving, with screw fixation; NC
• C8014 - Cystourethroscopy, with ureteroscopy and/or pyeloscopy, with lithotripsy, use of a suction enabled ureteral access sheath, with irrigation (if performed); NC
• C9310 - Injection, leucovorin calcium (avyxa), 1 mg; NPA
• G0574 -Management of new patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI model (services must be furnished within a patient's eligible residential care community, including assisted living facilities, board and care homes, or other qualifying residential settings where dementia care services are provided); NC
• G0575 -Management of established patient with dementia residing in an eligible residential care community, for use only in a Medicare-approved CMMI model (services must be furnished within a patient's eligible residential care community, including assisted living facilities, board and care homes, or other qualifying residential settings where dementia care services are provided); NC
• G0669 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); initial 12-month period; per month; NC
• G0670 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of early cardio-kidney-metabolic (ECKM) conditions (hypertension, or two or more of: dyslipidemia, obesity/overweight with central obesity marker, prediabetes); follow-on 12-month period; per month; NC
• G0671 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3a or 3b, atherosclerotic cardiovascular disease); initial 12-month period; per month; NC
• G0672 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of cardio-kidney-metabolic (CKM) conditions (one or more of: diabetes mellitus, chronic kidney disease stage 3a or 3b, atherosclerotic cardiovascular disease); follow-on 12-month period; per month; NC
• G0673 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of musculoskeletal (MSK) conditions (chronic musculoskeletal pain); initial 12-month treatment period; per month; NC
• G0674 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of behavioral health (BH) conditions (one or more of: depression, anxiety); initial 12-month period; per month; NC
• G0675 - Outcome-aligned payment (OAP) for technology-enabled chronic care management of behavioral health (BH) conditions (one or more of: depression, anxiety); follow-on 12-month period; per month; NC
• G0676 - Standard co-management service payment for documented review of clinical updates from access participant managing cardio-kidney-metabolic conditions (early cardio-kidney-metabolic [ECKM] or cardio-kidney-metabolic [CKM] track); per rev; NC
• G0677 - Standard co-management service payment for documented review of clinical updates from access participant managing musculoskeletal (MSK) conditions; per rev; NC
• G0678 - Standard co-management service payment for documented review of clinical updates from access participant managing behavioral health (BH) conditions (depression, anxiety); per rev; NC

Prior Authorization Process

• Advantage MD, EHP, Priority Partners, USFHP: Please use our secure online portal, Availity, to submit electronic prior authorization requests. For codes subject to prior authorization through EviCore, providers should submit prior authorization requests via the EviCore portal through Availity, the EviCore portal directly, or, if the portal cannot be accessed, by calling EviCore at 866-220-3071.
• USFHP providers can also submit prior authorization requests to the Johns Hopkins Health Plans Utilization Management (UM) department using these dedicated fax numbers: 410-424-2602 or 410-424-2603.