MedicaidPrior AuthHigh impact
[Ohio] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·OH · Rheumatology, Hematology, Oncology +4 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 4, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid is adding 8 specialty pharmacy drugs to prior authorization requirements when billed under the medical benefit, and implementing step therapy reviews for Opdivo (nivolumab) and Qvantig (nivolumab hyaluronidase-nvhy). Practices must begin requesting prior authorization for continued patient use of these medications on or after the effective date, and include NDC codes on all medical claims for these drugs.
Action Required
By September 30, 2026: Billing team must update authorization workflows and billing system rules to require prior authorization for the following drugs when billed on medical claims: Adbry (tralokinumab), Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), Ocrevus/Zunovo (ocrelizumab/hyaluronidase-ocsq), Ponlimsi (denosumab-adet), Releuko (filgrastim-ayow), Skytrofa (lonapegsomatropin-tcgd), Tezspire (tezepelumab-ekko), and Vyalev (foslevodopa-foscarbidopa). Update clinical staff and providers to understand that patients currently receiving these medications without prior authorization will require authorization requests upon renewal or new prescriptions after October 1, 2026. Ensure all medical claims for these drugs include NDC codes. For Opdivo and Qvantig, implement step therapy review requirements in addition to medical necessity review upon prior authorization initiation or renewal. Providers must consult the Clinical Criteria documents and Ohio UPDL for specific authorization criteria. Failure to obtain prior authorization will result in claim denials. Use Availity Chat with Payer or contact Anthem for authorization questions.