CommercialPrior AuthHigh impact
[Georgia] Specialty pharmacy updates — July 2026
Anthem BCBS·GA · Pharmacy, Hematology, Oncology +1 more·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield (Georgia) is implementing new prior authorization requirements for four specialty pharmacy drugs (Fesilty, Loargys, Vykoura, and Yuviwel), adding quantity limits to two drugs (Loargys and Yuviwel), and updating clinical criteria for eight drug classes that may result in previously covered services being denied as not medically necessary. Providers must begin requesting prior authorization for affected specialty medications on or after the effective date, and including NDC codes on claims will expedite processing.
Action Required
By September 15, 2026: Billing team and clinical staff must identify all patients currently receiving Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), or Yuviwel (navepegritide) to prepare for prior authorization requirements. Update billing software to require prior authorization submission for HCPCS codes C9399, J3590, and J3490 billed with clinical criteria CC-0149, CC-0301, CC-0104, and CC-0300 effective October 1, 2026. Implement quantity limit controls in billing system for Loargys (J3590) and Yuviwel (J3490). Train all providers and coding staff on the eight updated clinical criteria documents (CC-0003, CC-0058, CC-0065, CC-0104, CC-0124, CC-0128, CC-0142, CC-0236) to ensure medical necessity documentation is complete before claim submission. Note that oncology use of Vykoura (leucovorin calcium) is managed by Carelon Medical Benefits Management, not Anthem's specialty drug review team. Ensure NDC codes are included on all specialty pharmacy claims to expedite processing. Beginning October 1, 2026: Do not submit claims for affected specialty pharmacy drugs without prior authorization—claims will be denied. Reference Anthem's provider portal at https://anthem.com/provider for complete clinical criteria documents.