← Back to list
[Georgia] Specialty pharmacy updates
Act
by Nov 15, 2026
Effective date
Dec 1, 2026
Identified
Sep 2, 2026
Summary
Anthem Blue Cross Blue Shield Georgia is implementing new prior authorization and quantity limit requirements for 5 specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty drugs. Billing teams must request prior authorization for affected medications and include NDC codes on claims to expedite processing; previously covered patients may require new authorization for continued medication use.
Get alerts when payers change rules like this one
We check Anthem BCBS and other payers every day and email you when a change matches your specialty and state.
Get Anthem BCBS alertsPolicy Monitoring is free. No card required.
What to do
by Nov 15, 2026 · 7 steps
01Billing team must update systems to require prior authorization submission for all claims dated on or after December 1, 2026 containing HCPCS codes C9399, J3590, or J9999 (specialty pharmacy drugs: Saphnelo, Hepcludex, Decnupaz, Lumvoa, and Trutakna).
02For quantity limit drugs (Saphnelo, Lumvoa, Trutakna), configure system to flag claims exceeding approved quantities.
03Notify all providers that patients currently receiving these medications without prior authorization will need new PA requests submitted before December 1, 2026 for continued coverage.
04Include NDC codes on all specialty pharmacy claims to expedite processing.
05Review the revised clinical criteria (CC-0057, CC-0077, CC-0099, CC-0112, CC-0119, CC-0125, CC-0162, CC-0237, CC-0243, CC-0276, CC-0281) for Krystexxa, Palynziq, Abraxane, Xofigo, Yervoy, Opdivo, Tepezza, Qalsody, Vyjuvek, Tryngolza, and Opdivo Qvantig, as previously approved therapies may now be deemed not medically necessary and require new authorization.
06Claims without required prior authorization will be denied.
07For oncology use of Decnupaz, route prior authorization requests to Carelon Medical Benefits Management, not Anthem's medical specialty drug review team.
Codes mentioned
C9399J3590J9999
Original notice
[Georgia] Specialty pharmacy updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[New York] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Ohio] Specialty pharmacy updates — November 2026HighEffective Feb 1, 2027 · Pharmacy[Virginia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Georgia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · PharmacyBrowse every Anthem BCBS change in the policy list