CommercialPrior AuthMedium impact
[Ohio] Specialty pharmacy updates for May 2026
Anthem BCBS·OH · Pharmacy, Oncology, Endocrinology +4 more·Pharmacy
Effective date
Aug 1, 2026
We identified it
May 3, 2026
Summary
Effective August 1, 2026, Anthem is implementing new prior authorization, quantity limit, step therapy, and site of care requirements for 16 specialty pharmacy medications across multiple clinical criteria documents. Billing teams must update systems to require prior authorization for these drugs and verify step therapy status (non-preferred medications require step therapy) before claims submission. Patients currently receiving these medications without authorization may be affected, requiring proactive outreach.
Action Required
By July 15, 2026: Billing team must update prior authorization requirements in billing software to require pre-authorization for all 16 specialty pharmacy medications listed (Bonscresa, Lerochol, Nufymco, Oziltus, Rybrevant Faspro, Yartemlea, Zycubo, Azmiro, Bildyos, Bosaya, Fensolvi, Gamifant, Imaavy, Mircera, Nulibry, Papzimeos, Qfitlia, Somatuline Depot, Triptodur) effective August 1, 2026. Configure system to flag Bonscresa, Lerochol, Nufymco, and Oziltus as non-preferred requiring step therapy. Implement quantity limit validation for Bonscresa, Lerochol, Nufymco, and Zycubo. Update site of care requirements for all medications listed. Notify providers in writing of new requirements and access Clinical Criteria documents. Before August 1, 2026: Identify and contact patients currently receiving these medications without prior authorization to obtain retroactive authorization or notify of coverage changes. Failure to obtain prior authorization will result in claim denials.