CommercialPrior AuthHigh impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem BCBS·OH · Pharmacy, Hematology, Oncology +3 more·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 implementing new prior authorization requirements for four specialty pharmacy drugs, quantity limits for two drugs, and updated clinical criteria that may result in previously covered services being denied. Billing teams must begin requesting prior authorization for Fesilty, Loargys, Vykoura, and Vykoura (with oncology managed separately by Carelon), and include NDC codes on claims to expedite processing of NOC-billed drugs.
Action Required
By September 15, 2026: Billing team must update billing software and prior authorization workflows to require prior authorization for specialty pharmacy claims using HCPCS codes C9399 (Fesilty, Loargys, Vykoura), J3590 (Fesilty, Loargys), and J3490 (Vykoura, Yuviwel) effective October 1, 2026. Implement quantity limit edits in billing system for Loargys and Yuviwel claims. Providers and clinical staff must review updated clinical criteria documents for CC-0003, CC-0058, CC-0065, CC-0104, CC-0124, CC-0128, CC-0142, and CC-0236 at https://anthem.com/provider to understand new medical necessity standards. All specialty pharmacy claims must include National Drug Code (NDC) on the claim to expedite processing. For oncology uses of Vykoura (CC-0104), direct prior authorization requests to Carelon Medical Benefits Management, not Anthem. Failure to obtain required prior authorization will result in claim denials. Update encounter forms and clinical documentation templates to ensure providers include necessary medical necessity information for specialty pharmacy requests.