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[New York] Specialty pharmacy updates
Act
by Nov 30, 2026
Effective date
Dec 1, 2026
Identified
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.
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What to do
by Nov 30, 2026 · 6 steps
01Billing 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.
02Implement quantity limit checks in billing system for Saphnelo, Lumvoa, and Trutakna.
03Train billing and clinical staff to include NDC codes on all specialty pharmacy claims billed with NOC codes.
04Review Clinical Criteria documents CC-0202, CC-0303, CC-0304, CC-0305, and CC-0306 for specific PA requirements and medical necessity documentation.
05Alert 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.
06Coordinate with prescribers to gather additional documentation before the effective date.
If missed: Failure to obtain prior authorization will result in claim denials and service interruptions for patients currently on these medications.
Codes mentioned
C9399J3590J9999
Original notice
[New York] 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