CommercialPrior AuthMedium impact
[Ohio] Specialty pharmacy updates — July 2026
Anthem BCBS·OH · Oncology, Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 27, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield in Ohio is implementing new step therapy requirements for specialty pharmacy medications. Patients currently receiving Opdivo (nivolumab, J9299) and Opdivo Qvantig (nivolumab hyaluronidase-nvhy, J9289) without prior authorization will now require prior authorization review for continued use. Providers must request prior authorization for these medications on or after the effective date.
Action Required
By September 30, 2026: Billing team must update prior authorization protocols to require prior auth submission for CPT/HCPCS codes J9299 (Opdivo/nivolumab - preferred) and J9289 (Opdivo Qvantig/nivolumab hyaluronidase-nvhy - non-preferred) for all Anthem Ohio commercial patients. Providers must be notified that step therapy review is now required for these specialty pharmacy medications. Update billing system rules and encounter templates to flag these medications for prior authorization requests before claim submission. Clinical criteria documentation (CC-0125 for preferred, CC-0281 for non-preferred) should be reviewed and available to support prior authorization submissions. Failure to obtain prior authorization may result in claim denials for dates of service on or after October 1, 2026.