CommercialPrior AuthHigh impact
[New York] Specialty pharmacy updates — July 2026
Anthem BCBS·NY · Hematology, Oncology, Infectious Disease +2 more·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing new prior authorization requirements and quantity limits for four specialty pharmacy drugs effective October 1, 2026. Additionally, clinical criteria updates for eight drug categories may result in previously covered services now being found not medically necessary. Providers must begin obtaining prior authorization for affected medications on or after the effective date, and should include NDC codes on claims to expedite processing.
Action Required
By September 15, 2026: Billing team must update billing system to require prior authorization for the following specialty pharmacy drugs billed with HCPCS codes C9399, J3590, and J3490: Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), and Yuviwel (navepegritide). Implement quantity limit edits in billing software for Loargys and Yuviwel effective October 1, 2026. Provider education team must notify all prescribing clinicians that prior authorization is now required for these medications and that additional documentation may be requested to determine medical necessity. Update claim submission procedures to include NDC codes on all specialty pharmacy drug claims billed with NOC codes to expedite processing. Establish workflow to route oncology requests for Vykoura (leucovorin calcium) to Carelon Medical Benefits Management separate from Anthem's medical specialty drug review team. Failure to obtain required prior authorization will result in claim denials. Clinical Criteria documents CC-0003, CC-0058, CC-0065, CC-0104, CC-0124, CC-0128, CC-0142, and CC-0236 have been updated and may impact coverage determinations—obtain and review these updated criteria before October 1, 2026.