Medicare AdvantagePrior AuthMedium impact
[Ohio] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·OH · Oncology, Pharmacy·Pharmacy
Effective date
Nov 1, 2026
We identified it
Jul 23, 2026
Summary
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage in Ohio is expanding its specialty pharmacy precertification review process to include two additional Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must obtain precertification before administering these medications or claims will be rendered ineligible for reimbursement.
Action Required
Before November 1, 2026: Billing and clinical teams must implement precertification requirements for HCPCS codes J9999, C9399, C9339, and J3590 in the billing system for all Anthem Medicare Advantage Ohio patients. Update clinical protocols and staff training to require prior authorization submission before drug administration. Add these drug names (Decnupaz and Lumvoa) to the precertification checklist used by providers and billing staff. Failure to obtain precertification will result in claim denials and patient billing complications.