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Anthem BCBSCommercial · Prior Auth · Pharmacy · OH · Oncology, Hematology, PharmacyHigh impact

[Ohio] Specialty pharmacy updates — July 2026

Act
by Jun 15, 2026, the billing and clinical teams must
Effective date
Jul 1, 2026
Identified
Jun 26, 2026

Summary

Anthem Blue Cross and Blue Shield in Ohio is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria revisions effective October 1, 2026. Patients currently receiving Avlayah, Filkri, and Ponlimsi without prior authorization will require new authorization requests going forward, and multiple oncology drugs will have revised clinical criteria that may result in coverage denials.

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What to do

by Jun 15, 2026, the billing and clinical teams must · 5 steps
01Update the billing system and prior authorization workflow to require prior authorization for C9399 and J3590 codes when billed for Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), and Ponlimsi (denosumab-adet) effective July 1, 2026.
02Configure quantity limit alerts in the billing system for Avlayah and Ponlimsi.
03Establish step therapy rules marking Filkri and Ponlimsi as non-preferred with required step therapy review.
04Train clinical staff to understand that oncology cases for these medications will route to Carelon Medical Benefits Management.
05By October 1, 2026, review and update clinical criteria in the EMR for all revised Clinical Criteria documents (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) as these medications may no longer be medically necessary under new criteria.
If missed: Failure to obtain prior authorization before July 1, 2026 will result in claim denials for these specialty pharmacy medications.

Codes mentioned

C9399J3590

Original notice

[Ohio] Specialty pharmacy updates — July 2026
providernews.anthem.com · Always check the source before changing claims.
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Related changes

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[New York] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Ohio] Specialty pharmacy updates — November 2026HighEffective Feb 1, 2027 · Pharmacy[Virginia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Georgia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · PharmacyBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesOH policy changesOncologyHematologyPharmacyCode C9399Code J3590

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