CommercialPrior AuthMedium impact
[Georgia] Clinical Criteria updates for specialty pharmacy are available
Anthem BCBS·GA · Pharmacy, Oncology·Pharmacy
Effective date
Mar 1, 2026
We identified it
May 3, 2026
Summary
Effective March 1, 2026, Anthem Blue Cross Blue Shield (Georgia) is implementing new Clinical Criteria for 11 specialty pharmacy drugs and drug classes. These criteria may result in services previously covered being determined as not medically necessary, requiring prior authorization review by the medical specialty drug review team (or Carelon for oncology drugs). Billing teams must ensure prior authorization is obtained before dispensing these specialty medications to avoid claim denials.
Action Required
Before March 1, 2026: Billing and pharmacy teams must (1) Review the 11 affected specialty pharmacy medications and their Clinical Criteria (CC-0291, CC-0012, CC-0035, CC-0241, CC-0034, CC-0013, CC-0282, CC-0067, CC-0159, CC-0250, CC-0220) available at the source URL; (2) Update pharmacy systems and billing workflows to require prior authorization for all affected drugs before dispensing; (3) Identify which drugs are oncology-related (to be routed to Carelon Medical Benefits Management) versus non-oncology (to be routed to Anthem's medical specialty drug review team); (4) Train pharmacy and billing staff on the new routing and prior authorization submission process; (5) Update provider communication materials to notify prescribers of the new requirements. Failure to obtain prior authorization will result in claim denials for these specialty medications under Anthem Georgia commercial plans.