[Georgia] Specialty pharmacy updates — July 2026

REQUIREMENTS: By June 15, 2026: Billing and clinical teams must prepare for implementation of new prior authorization requirements for Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), and Ponlimsi (denosumab-adet) when billed with HCPCS codes C9399 and J3590. By June 30, 2026: - Update billing system to require prior authorization for all claims containing C9399 and J3590 codes for the three affected medications effective July 1, 2026 - Review Anthem Clinical Criteria documents (CC-0002, CC-0027, CC-0302) to understand medical necessity requirements - Notify providers that step therapy and quantity limits will apply to Filkri and Ponlimsi beginning July 1, 2026 - Flag that Filkri and Ponlimsi are non-preferred drugs requiring step therapy documentation - For oncology uses of Filkri and Ponlimsi, configure system to route prior authorization requests to Carelon Medical Benefits Management By September 15, 2026: Billing and clinical teams must review revised clinical criteria (CC-0002, CC-0048, CC-0087, CC-0092, CC-0094, CC-0102, CC-0105, CC-0106, CC-0107, CC-0108, CC-0124, CC-0130, CC-0145, CC-0165, CC-0240, CC-0262) effective October 1, 2026 to identify potential coverage denials for previously authorized medications. Update billing software to reflect any coverage changes. Consequences: Claims submitted without required prior authorization will be denied. Prior authorization requests may be rejected if medical necessity documentation is insufficient. Previously covered services may be denied as not medically necessary under revised clinical criteria.