CommercialPrior AuthMedium impact
[Ohio] Specialty pharmacy updates — February 2026
Anthem BCBS·OH · Oncology, Hematology, Rheumatology +2 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Anthem Ohio is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy drugs effective May 1, 2026. Practices must begin requesting prior authorization for these medications on dates of service after May 1, 2026, and include NDC codes on claims to expedite processing. Patients currently receiving these medications without prior authorization will require authorization going forward to avoid claim denials.
Action Required
By April 30, 2026: Billing team must update prior authorization workflows to require approval for all 14 specialty pharmacy drugs listed (Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, Qivigy, Radicava, and Xtrenbo) when billed with HCPCS codes C9399, J3590, J3490, J9999, or J1301. Providers must submit prior authorization requests for these medications before May 1, 2026 for continued patient use. Update claim scrubbing logic to flag claims missing NDC codes for these drugs to expedite processing. Educate clinical staff that oncology-related specialty drugs will be reviewed by Carelon Medical Benefits Management (separate entity), while non-oncology specialty drugs are reviewed by Anthem's medical specialty drug review team. Implement quantity limit monitoring for denosumab biosimilars, aflibercept-boav, pembrolizumab-berahyaluronidase, and edaravone. Mark denosumab biosimilars, immune globulin products, aflibercept-boav, and pembrolizumab-berahyaluronidase as non-preferred requiring step therapy. Failure to obtain prior authorization will result in claim denials.