Medicare AdvantagePrior AuthMedium impact
[Georgia] Expansion of the specialty pharmacy precertification list
Anthem BCBS·GA · Oncology, Ophthalmology, Nephrology +1 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross Blue Shield (Georgia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Five specialty Part B drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea) now require prior authorization, and three of these drugs are also subject to step therapy review before precertification approval.
Action Required
By June 1, 2026: Billing team must update prior authorization workflows to require precertification for claims using HCPCS codes C9399, J3590, and J9999 for the five listed specialty drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, Yartemlea) for Anthem Georgia Medicare Advantage members only. Verify step therapy requirements are active in billing system for Bonscresa, Nufymco, and Oziltus per Clinical Criteria guidelines (CC-0027, CC-0072). Train clinical and billing staff to initiate precertification at the time of order—step therapy will not apply to members already receiving these medications. Reference Anthem's Clinical Criteria at https://anthem.com/provider for specific approval criteria. Claims submitted without required prior authorization will be denied.