MedicaidPrior AuthHigh impact
[New York] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·NY · Pharmacy·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 27, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross New York Medicaid will require prior authorization for five specialty pharmacy drugs billed under the medical benefit: Decnupaz, Hepcludex, Lumvoa, Saphnelo Autoinjector, and Trutakna. Patients currently receiving these medications without prior authorization will require PA requests going forward. All medical claims must include the National Drug Code (NDC) for processing.
Action Required
By September 30, 2026: Billing team must implement prior authorization workflow for the following specialty drugs billed on medical claims: Decnupaz (pivekimab sunirine-pvzy), Hepcludex (bulevirtide-gmod), Lumvoa (veligrotug-vvze), Saphnelo Autoinjector (anifrolumab-fnia), and Trutakna (atacicept). Update billing system to flag these medications and require prior auth requests before claim submission. Providers must review clinical criteria (CC-0304, CC-0303, CC-0305, CC-0202, CC-0306) on the payer's Clinical Criteria website. Ensure all medical claims include the NDC for these drugs. Front desk and billing staff should be trained on the new requirement. Access Availity Chat with Payer (availity.com) for questions about authorization. Failure to obtain prior authorization will result in claim denials for these medications.