Medicare AdvantagePrior AuthMedium impact
[Ohio] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·OH · 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 (Ohio) is expanding its specialty pharmacy precertification requirements to include two Medicare Part B drugs: Filkri (filgrastim-laha) and Ponlimsi (denosumab-adet). Both drugs will now require prior authorization and step therapy review (except for members already actively receiving these medications). Billing teams must implement precertification workflows for these HCPCS codes to avoid claim denials.
Action Required
By September 15, 2026: Billing team must update the practice management system to require prior authorization for HCPCS codes C9399 and J3590 (Filkri and Ponlimsi) when billed to Anthem Blue Cross and Blue Shield Medicare Advantage plans in Ohio, effective October 1, 2026. Configure step therapy requirements in the authorization workflow per Clinical Criteria Guidelines CC-0002 and CC-0027. Update provider encounter templates and billing checklists to alert clinicians that precertification is required before prescribing or administering these drugs. Inform all nursing and clinical staff administering specialty pharmacy medications. Claims submitted without required precertification authorization will be denied. Reference Availity for authorization submissions and contact Anthem provider support for clinical criteria questions.