CommercialPrior AuthHigh impact
[New York] Specialty pharmacy updates — July 2026
Anthem BCBS·NY · Oncology, Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 27, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing new step therapy requirements for specialty pharmacy medications effective October 1, 2026. Nivolumab (Opdivo) products now require prior authorization review for continued patient use, even if patients are currently receiving these medications without prior auth. Practices must begin requesting prior authorization for these oncology medications on or after the effective date.
Action Required
By September 15, 2026: Billing team and providers must update workflows to require prior authorization for nivolumab products (HCPCS J9299 for Opdivo and J9289 for Opdivo Qvantig) on all Anthem Blue Cross and Blue Shield commercial claims with dates of service on or after October 1, 2026. Update billing software, EMR templates, and prior authorization submission protocols to flag these medications automatically. Notify all oncology providers that step therapy requirements now apply to these previously non-authorized medications. Review the complete Clinical Criteria documents CC-0125 and CC-0281 on Anthem's website to understand specific step therapy requirements. Claims submitted without prior authorization after October 1, 2026 will likely be denied or subject to recoupment.