Medicare AdvantagePrior AuthMedium impact
[Georgia] Expansion of specialty pharmacy precertification list
Anthem BCBS·GA · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Blue Cross Blue Shield (Georgia) is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and adding step therapy reviews for Keytruda Qlex and Tecentriq Hybreza. All specialty pharmacy claims for these medications will require precertification; claims submitted without precertification approval may be deemed ineligible for reimbursement.
Action Required
By May 31, 2026: Billing and precertification teams must (1) update billing system and prior authorization workflows to require precertification initiation for all specialty pharmacy drugs listed (Armlupeg, Blenrep, Exdensur, Jubereq, Osvyrti, Poherdy, Redemplo, and Spravato); (2) configure system to apply step therapy criteria per Clinical Criteria Guidelines (CC-0002, CC-0027, CC-0124, CC-0128) when processing Keytruda Qlex and Tecentriq Hybreza precertification requests; (3) ensure step therapy does NOT apply to members already actively receiving original Keytruda or Tecentriq; (4) train providers and staff that noncompliance with precertification requirements will result in claim denials. Providers should access publicly available Clinical Criteria Guidelines on the Anthem provider website to understand specific approval criteria.