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[New York] Specialty pharmacy updates
Act
by Dec 31, 2026
Effective date
Jan 1, 2027
Identified
Sep 26, 2026
Summary
Anthem Blue Cross and Blue Shield in New York is implementing new prior authorization requirements for three specialty oncology medications (Avgemsi, Docivyx, Beizray) effective January 1, 2027. Additionally, step therapy requirements are being applied to pemetrexed, bendamustine, and docetaxel products, with specific formulations designated as preferred or non-preferred, requiring step therapy protocols before dispensing non-preferred agents.
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What to do
by Dec 31, 2026 · 5 steps
01Billing team and oncology providers must implement prior authorization protocols for gemcitabine (Avgemsi, J9184), docetaxel (Docivyx J9172, Beizray J9174) when treating New York commercial members.
02Update billing software and clinical documentation templates to require prior auth submission through Carelon Medical Benefits Management for these three medications.
03Simultaneously, update step therapy workflows to enforce preferred/non-preferred designations for pemetrexed (J9305, J9294, J9296, J9297, J9314, J9322, J9323, J9304, J9324, J9292), bendamustine (J9033, J9034, J9036, J9056), and docetaxel (J9171, J9232, J9172, J9174) products—non-preferred formulations (Pemrydi RTU, Axtle, Belrapzo, Vivimusta, Docivyx, Beizray) require step therapy completion before dispensing.
04Train providers to document medical necessity for all specialty pharmacy requests.
05Claims submitted without required prior authorization or step therapy completion will be denied for dates of service on or after January 1, 2027.
Codes mentioned
J9184J9172J9174J9305J9294J9296J9297J9314J9322J9323J9304J9324J9292J9033J9034J9036J9056J9201J9196J9232
Original notice
[New York] Specialty pharmacy updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Ohio] 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