Medicare AdvantagePrior AuthMedium impact
[Georgia] Anthem expands specialty pharmacy precertification list
Anthem BCBS·GA · Pharmacy, Oncology, Rheumatology +1 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Blue Cross Blue Shield in Georgia is expanding its specialty pharmacy precertification list to include 11 Medicare Part B drugs, adding both standard prior authorization requirements and step therapy reviews for certain medications. Billing teams must implement precertification processes for these drugs and ensure step therapy requirements are met before claims are submitted; noncompliance will result in claim denials.
Action Required
By April 30, 2026: Billing team must update billing system and prior authorization workflows to require precertification for all specialty pharmacy drugs listed in this policy when billed to Anthem Georgia Medicare Advantage members (HCPCS codes C9399, J3590, J3490, J9999 with the specific drug names: denosumab variants [Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Xtrenbo], aflibercept [Eydenzelt], elamipretide [Forzinity], immune globulin products [Gammagard Liquid ERC, Qivigy], gemcitabine [Inlexzo], and pembrolizumab [Keytruda Qlex]). Implement step therapy precertification review for denosumab and aflibercept products per Clinical Criteria Guidelines (CC-0027, CC-0072, CC-0003) before claim submission. Add precertification requirement to prior auth protocols in billing software and provider encounter templates. Contact Anthem or access their Clinical Criteria Guidelines page to document specific step therapy requirements. Ensure providers are notified that step therapy does not apply to members already receiving these medications. Failure to obtain precertification will result in claim denials.