MedicaidPrior AuthHigh impact
[New York] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·NY · Oncology, Hematology, Pharmacy·Provider Bulletin
Effective date
Sep 1, 2026
We identified it
Jul 16, 2026
Summary
Effective September 1, 2026, three specialty pharmacy drugs (Avlayah, Filkri, and Ponlimsi) billed under the medical benefit will now require prior authorization for New York Medicaid. Additionally, two drugs (Filkri and Opdivo/Opdivo Qvantig) will be subject to step therapy review upon prior authorization initiation or renewal. All medical claims for these drugs must include the National Drug Code (NDC) for processing.
Action Required
By August 31, 2026: Billing team must implement prior authorization requirements for Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), and Ponlimsi (denosumab-adet) on all New York Medicaid medical claims. Update billing system to require NDC codes on all claims for these drugs. Providers must obtain prior authorization before dispensing these medications to existing and new patients. Implement step therapy review process for Filkri (non-preferred) and Opdivo/Opdivo Qvantig (preferred) during prior authorization initiation and renewal. Reference Clinical Criteria documents CC-0302, CC-0002, CC-0027, CC-0125, and CC-0281 for specific approval criteria. Train clinical staff to initiate prior authorization requests through Availity Chat with Payer (https://Availity.com) during business hours. Claims submitted without prior authorization or missing NDC codes will be denied.