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[Ohio] Specialty pharmacy updates
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
Sep 2, 2026
Summary
Anthem Blue Cross and Blue Shield (Ohio) is implementing new prior authorization requirements and quantity limits for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for eleven additional specialty medications. Billing teams must begin requesting prior authorization for these drugs on or after the effective date, and include NDC codes on claims to expedite processing.
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What to do
by Nov 30, 2026 · 7 steps
01Billing and clinical teams must update systems and workflows to require prior authorization for specialty pharmacy claims using HCPCS codes C9399, J3590, and J9999.
02Configure billing software to mandate prior authorization submission for Saphnelo, Hepcludex, Decnupaz, Lumvoa, and Trutakna before claim submission.
03Update encounter templates and provider documentation checklists to prompt for medical necessity information, as certain medications require additional documentation.
04Implement quantity limit monitoring in billing system for Saphnelo, Lumvoa, and Trutakna.
05Train providers to include National Drug Code (NDC) on all specialty pharmacy claims to expedite processing.
06Reference updated Clinical Criteria documents (CC-0202, CC-0303, CC-0304, CC-0305, CC-0306, and revisions to CC-0057, CC-0077, CC-0099, CC-0112, CC-0119, CC-0125, CC-0162, CC-0237, CC-0243, CC-0276, CC-0281) when determining medical necessity.
07Note: Oncology use of Decnupaz is managed by Carelon Medical Benefits Management, not Anthem.
If missed: Failure to obtain prior authorization as of December 1, 2026, will result in claim denials for affected specialty pharmacy medications.
Codes mentioned
C9399J3590J9999
Original notice
[Ohio] 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