Medicare AdvantagePrior AuthMedium impact
[Georgia] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·GA · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Georgia is adding two specialty Medicare Part B drugs (Filkri and Ponlimsi) to its precertification review process. Both drugs will also require step therapy review upon precertification initiation, meaning patients must meet clinical criteria before coverage is approved. Claims submitted without prior authorization will be denied.
Action Required
By September 15, 2026: Billing team must update claims processing system to require prior authorization for HCPCS codes C9399 and J3590 (Filkri and Ponlimsi) for all Anthem Medicare Advantage Georgia members. Providers ordering these medications must initiate precertification through Anthem before dispensing; step therapy protocols will be applied during precertification review per Clinical UM Guidelines CC-0002 and CC-0027. Update EMR/EHR workflow to flag these medications for prior auth. Contact Anthem through Availity or provider portal to access Clinical Criteria Guidelines for step therapy requirements. Failure to obtain precertification will result in claim denials. Exemption: No step therapy applies to members already actively receiving these medications.