MedicaidPrior AuthHigh impact
[California] Prior authorization and step therapy updates
Anthem BCBS·CA · Oncology, Hematology, Internal Medicine·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Jul 15, 2026
Summary
Effective November 1, 2026, Anthem Blue Cross Medi-Cal (California Medicaid) is adding four specialty pharmacy drugs to prior authorization requirements and implementing step therapy reviews for multiple pegfilgrastim and filgrastim biosimilars plus nivolumab. All medical claims for these drugs must include NDC codes and will require prior authorization initiation or renewal, with step therapy applied during review.
Action Required
By October 15, 2026: Billing team must update prior authorization workflow in billing system and EMR to require prior auth requests for Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), Ponlimsi (denosumab-adet), and Udenyca/Udenyca Onbody (pegfilgrastim-cbqv) on all medical claims dated on or after November 1, 2026. Simultaneously, implement step therapy review protocol for all pegfilgrastim biosimilars (non-preferred: Armlupeg, Fulphila, Fylnetra, Nyvepria, Rolvedon, Ryzneuta, Stimufend, Ziextenzo; preferred: Neulasta, Neulasta OnPro, Udenyca, Udenyca Onbody, Zarxio), filgrastim biosimilars (non-preferred: Filkri, Granix, Neupogen, Nivestym, Nypozi, Releuko; preferred: Zarxio), and nivolumab products (preferred: Opdivo; non-preferred: Opdivo Qvantig). Step therapy must be applied upon prior authorization initiation or renewal in addition to medical necessity review per Clinical Criteria documents (CC-0125, CC-0281, CC-0002, CC-0027, CC-0302). Ensure all medical claims include NDC codes for these specialty pharmacy drugs. Verify staff understands preferred vs. non-preferred status to support step therapy determinations. Failure to obtain prior authorization will result in claim denials for California Medi-Cal members. Contact Anthem Blue Cross via Availity Chat with Payer during business hours for clarification on specific clinical criteria.