CommercialPrior AuthHigh impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem BCBS·OH · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jul 1, 2026
We identified it
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.
Action Required
By June 15, 2026, the billing and clinical teams must: (1) Update 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; (2) Configure quantity limit alerts in the billing system for Avlayah and Ponlimsi; (3) Establish step therapy rules marking Filkri and Ponlimsi as non-preferred with required step therapy review; (4) Train clinical staff to understand that oncology cases for these medications will route to Carelon Medical Benefits Management; (5) By 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. Failure to obtain prior authorization before July 1, 2026 will result in claim denials for these specialty pharmacy medications.