CommercialPrior AuthHigh impact
[New York] Specialty pharmacy updates — July 2026
Anthem BCBS·NY · Oncology, Hematology, Rheumatology +2 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jun 26, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria updates effective October 1, 2026. Patients currently receiving Avlayah, Filkri, and Ponlimsi may require prior authorization going forward, and 16 additional oncology and specialty drugs will have revised clinical criteria that may result in coverage denials.
Action Required
By June 15, 2026: Billing team must update authorization workflow to require prior authorization for Avlayah (C9399, J3590), Filkri (C9399, J3590), and Ponlimsi (C9399, J3590) effective July 1, 2026. For oncology use of Filkri and Ponlimsi, route prior authorization requests through Carelon Medical Benefits Management. Implement quantity limits for Avlayah and Ponlimsi in billing system. Mark Filkri and Ponlimsi as non-preferred with step therapy requirements in clinical decision support. By September 15, 2026: Review 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) effective October 1, 2026 and update billing system rules to reflect potentially reduced coverage for 16 specialty drugs. Train providers on new requirements. Claims processed without required prior authorization will be denied or delayed.