MedicaidPrior AuthMedium impact
[Ohio] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·OH · Pharmacy, Hematology·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 14, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid now requires prior authorization for four specialty pharmacy drugs billed under the medical benefit: Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), and Yuviwel (navepegritide). Billing teams must obtain prior authorization before processing claims for these medications or face claim denials. National Drug Codes (NDCs) must be included on all medical claims for these drugs.
Action Required
By June 15, 2026: Billing team must implement prior authorization requirement for four specialty pharmacy drugs billed on medical claims: Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), and Yuviwel (navepegritide). Update billing software to flag these medications for prior authorization review before claim submission. Ensure all medical claims for these drugs include the National Drug Code (NDC). Provider staff must reference Clinical Criteria website (CC-0149, CC-0301, CC-0104, CC-0300) to verify clinical criteria requirements before requesting authorization. Use Availity Chat with Payer (https://Availity.com) during business hours for authorization questions. Failure to obtain prior authorization will result in claim denials for continued use after July 1, 2026.