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[Ohio] Specialty pharmacy updates
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 26, 2026
Summary
Anthem Blue Cross and Blue Shield Ohio is implementing new prior authorization requirements and step therapy protocols for specialty pharmacy oncology medications effective January 1, 2027. Starting that date, providers must request prior authorization for Avgemsi (gemcitabine), Docivyx (docetaxel), and Beizray (docetaxel) before dispensing, and must follow step therapy requirements for pemetrexed, bendamustine, and docetaxel products, with preferred and non-preferred formulations designated.
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What to do
by Dec 31, 2026 · 6 steps
01Billing and clinical teams must implement the following changes.
02Update billing system and prior authorization workflows to REQUIRE prior authorization for J9184 (Avgemsi/gemcitabine), J9172 (Docivyx/docetaxel), and J9174 (Beizray/docetaxel) for all dates of service on or after January 1, 2027 — claims submitted without prior auth will be denied.
03Configure step therapy requirements in the billing system for pemetrexed products (J9305, J9294, J9296, J9297, J9314, J9322, J9323, J9304, J9324, J9292) and bendamustine products (J9033, J9034, J9036, J9056) and docetaxel products (J9171, J9232, J9172, J9174), designating preferred vs. non-preferred formulations per the policy.
04Train billing staff and providers that prior authorization requests may require additional documentation to establish medical necessity.
05Notify all oncology providers, specialty pharmacy partners, and Carelon Medical Benefits Management contacts of the changes.
06Review and update all internal policies, encounter forms, and authorization templates to reflect new requirements.
If missed: Failure to obtain prior authorization will result in claim denials.
Codes mentioned
J9184J9172J9174J9305J9294J9296J9297J9314J9322J9323J9304J9324J9292J9033J9034J9036J9056J9201J9196J9232
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 updatesHighEffective Jan 1, 2027 · Pharmacy[Virginia] Specialty pharmacy updatesHighEffective Jan 1, 2027 · Pharmacy[Georgia] Specialty pharmacy updatesHighEffective Jan 1, 2027 · Pharmacy[New York] Prior authorization and step therapy updates for medications billed under the medical benefitMediumEffective Dec 1, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list