Medicare AdvantagePrior AuthMedium impact
[New York] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·NY · Oncology, Hematology, Infectious Disease·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross and Blue Shield Medicare Advantage is expanding its specialty pharmacy precertification list effective October 1, 2026, to include two Medicare Part B drugs: Filkri (filgrastim-laha) and Ponlimsi (denosumab-adet). These drugs will now require prior authorization review, and step therapy precertification will be added to the review process for both medications.
Action Required
By September 15, 2026: Billing team and providers must implement prior authorization requirements for Filkri (filgrastim-laha) and Ponlimsi (denosumab-adet) when billing HCPCS codes C9399 and J3590 to Anthem Medicare Advantage in New York. Update billing system to require precertification submission before claim submission. Implement step therapy verification in the authorization process—note that step therapy does NOT apply if members are already actively receiving these medications. Train providers to document active medication status in precertification requests. Update encounter templates and prior auth checklists. Failure to obtain precertification will result in claim denials. Reference Clinical Criteria Guidelines CC-0002 and CC-0027 (Non-Preferred status) and use Availity Chat with Payer for authorization questions.