CommercialPrior AuthHigh impact
[Georgia] Specialty pharmacy updates for May 2026
Anthem BCBS·GA · Oncology, Hematology, Endocrinology +3 more·Pharmacy
Effective date
Aug 1, 2026
We identified it
May 3, 2026
Summary
Effective August 1, 2026, Anthem Georgia is implementing new prior authorization, quantity limit, step therapy, and site of care requirements for 17 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before the effective date, as patients currently receiving these medications without authorization will now require approval for continued use.
Action Required
By July 31, 2026: Billing team must update billing system to require prior authorization for all specialty pharmacy claims using the affected HCPCS codes (C9399, J3590, J3490, J9999, J1072, Q5162, Q5161, J1951, J9210, J9256, J0888, J1809, J3404, J7174, J1930, J1932, J3316). Configure system to apply quantity limits and step therapy edits for the specified drugs. For oncology medications (Bonscresa, Oziltus, Rybrevant Faspro), ensure requests route to Carelon Medical Benefits Management. Update provider encounter templates and clinical decision support to alert providers that prior authorization is now required for these medications. Train billing staff on new requirements. Notify patients receiving these medications that authorization may be needed for refills. Failure to obtain prior authorization will result in claim denials.