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Anthem BCBSMedicare Advantage · Prior Auth · Pharmacy · NY · Oncology, Hematology, Rheumatology +1 moreHigh impact

[New York] Specialty pharmacy precertification list expands

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 14, 2026

Summary

Anthem Blue Cross and Blue Shield (New York) is expanding its specialty pharmacy precertification requirements for Medicare Advantage plans. Effective January 1, 2027, step therapy will be added to the precertification review process for 10 Part B medications (denosumab, bendamustine, and pemetrexed formulations). Additionally, effective February 1, 2027, three new Part B drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will be included in the precertification review process. Noncompliance with these requirements may result in claim denial.

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What to do

by Jan 1, 2027 · 6 steps
01Billing team must implement step therapy precertification review for the 10 Part B medications listed (denosumab, bendamustine, and pemetrexed formulations with HCPCS codes J9033, J9034, J9036, J9056, J9305, J9314, J9322, J9323, J9294, J9296, J9297, and J9304) in the billing system for Anthem Medicare Advantage members in New York.
02Step therapy will apply upon initiation of precertification in addition to medical necessity review.
03Exemption: Step therapy does not apply to members currently receiving any of these medications.
04By February 1, 2027: Billing team must update the system to require precertification for three additional Part B drugs (golimumab-sldi, bevacizumab-vikg, isatuximab-irfc with codes C9399, J3590, J9999) for Anthem Medicare Advantage members in New York.
05Providers and billing staff should verify the Clinical Criteria Guidelines on Anthem's provider website for specific step therapy criteria.
06Consequence: Noncompliance with these new precertification requirements may result in claims being ineligible for reimbursement.

Codes mentioned

C9399J3590J9999J9033J9034J9036J9056J9305J9314J9322J9323J9294J9296J9297J9304

Original notice

[New York] Specialty pharmacy precertification list expands
providernews.anthem.com · Always check the source before changing claims.
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Related changes

See all Anthem BCBS changes →
[California] Specialty pharmacy precertification list expandsMediumNo effective date · Pharmacy[Ohio] Specialty pharmacy precertification list expandsHighEffective Jan 1, 2027 · Pharmacy[Virginia] Specialty pharmacy precertification list expandsHighEffective Jan 1, 2027 · Pharmacy[Georgia] Specialty pharmacy precertification list expandsMediumNo effective date · PharmacyBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesNY policy changesOncologyHematologyRheumatologyPharmacyCode C9399Code J3590Code J9999Code J9033Code J9034Code J9036Code J9056Code J9305Code J9314Code J9322Code J9323Code J9294Code J9296Code J9297Code J9304

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