MedicaidPrior AuthMedium impact
[Ohio] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·OH · Infectious Disease, Rheumatology, Internal Medicine·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 27, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid is implementing prior authorization requirements for five specialty pharmacy drugs billed under the medical benefit: Decnupaz, Hepcludex, Lumvoa, Saphnelo Autoinjector, and Trutakna. Providers must obtain prior authorization before dispensing these medications to continue patient treatment, and all claims must include the National Drug Code (NDC) for processing.
Action Required
By September 30, 2026: Billing team and clinical staff must implement prior authorization workflow for five specialty medications (Decnupaz/pivekimab sunirine-pvzy, Hepcludex/bulevirtide-gmod, Lumvoa/veligrotug-vvze, Saphnelo Autoinjector/anifrolumab-fnia, Trutakna/atacicept). Action items: (1) Update billing system to flag these medications for prior auth requirement; (2) Establish process to submit prior auth requests through Availity Chat with Payer or provider contact channels; (3) Train billing and clinical staff on new requirements; (4) Ensure all medical claims for these drugs include the appropriate NDC codes (required for processing); (5) Review specific clinical criteria on Anthem's Clinical Criteria website using codes CC-0304, CC-0303, CC-0305, CC-0202, and CC-0306. Consequence: Claims submitted without prior authorization will be denied, and patients may experience treatment delays.