CommercialPrior AuthHigh impact
[New York] Specialty pharmacy updates — February 2026
Anthem BCBS·NY · Oncology, Infectious Disease, Hematology +2 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Effective May 1, 2026, Anthem is implementing new prior authorization, quantity limit, and step therapy requirements for 14 specialty pharmacy drugs across multiple therapeutic areas. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must identify claims for these drugs and ensure prior authorization is obtained before or concurrent with claim submission to avoid denials.
Action Required
By April 30, 2026: Billing team must implement the following changes: (1) Update billing system to flag all claims with HCPCS codes C9399, J3590, J3490, J9999, and J1301 for specialty pharmacy drugs listed in this policy (Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, Qivigy, Radicava, Xtrenbo) to require prior authorization before claim submission. (2) Create internal workflow requiring providers to submit PA requests for these drugs with dates of service on or after May 1, 2026. (3) For oncology drugs (marked with asterisk in policy), route PA requests to Carelon Medical Benefits Management, Inc.; non-oncology drugs route to Anthem's medical specialty drug review team. (4) Update claim submission processes to include National Drug Code (NDC) on all specialty pharmacy claims to expedite processing. (5) Notify providers that these drugs are transitioning to quantity limit and step therapy review; consult Clinical Criteria document (http://anthem.ly/4pRSK8i) for specific limits and preferred agents. Failure to obtain prior authorization will result in claim denials for Anthem commercial plans in New York.