CommercialPrior AuthHigh impact
[New York] Specialty pharmacy updates
Anthem BCBS·NY · Pharmacy, Oncology, Rheumatology +3 more·Pharmacy
Effective date
Dec 1, 2026
We identified it
Sep 2, 2026
Summary
Anthem Blue Cross and Blue Shield is implementing new prior authorization and quantity limit requirements for five specialty pharmacy drugs effective December 1, 2026, and revising clinical criteria for 11 additional specialty medications. Billing teams must begin requesting prior authorization for affected medications on or after the effective date, and include NDC codes on claims to expedite processing. Previously covered patients may lose coverage if prior authorization is not obtained.
Action Required
By November 30, 2026: (1) Billing team must update prior authorization workflows to require PA submissions for Saphnelo (C9399, J3590), Hepcludex (C9399, J3590), Decnupaz (C9399, J9999 — oncology only via Carelon), Lumvoa (C9399, J3590), and Trutakna (C9399, J3590) for all dates of service on or after December 1, 2026. (2) Implement quantity limit checks in billing system for Saphnelo, Lumvoa, and Trutakna. (3) Train billing and clinical staff to include NDC codes on all specialty pharmacy claims billed with NOC codes. (4) Review Clinical Criteria documents CC-0202, CC-0303, CC-0304, CC-0305, and CC-0306 for specific PA requirements and medical necessity documentation. (5) Alert providers that 11 additional drugs (Krystexxa, Palynziq, Abraxane, Xofigo, Yervoy, Opdivo, Tepezza, Qalsody, Vyjuvek, Tryngolza, Opdivo Qvantig) have revised clinical criteria effective December 1, 2026 that may restrict previously approved uses. Coordinate with prescribers to gather additional documentation before the effective date. Failure to obtain prior authorization will result in claim denials and service interruptions for patients currently on these medications.