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Anthem BCBSCommercial · Prior Auth · Pharmacy · OH · Pharmacy, Oncology, Endocrinology +4 moreMedium impact

[Ohio] Specialty pharmacy updates for May 2026

Act
by Jul 15, 2026
Effective date
Aug 1, 2026
Identified
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.

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What to do

by Jul 15, 2026 · 6 steps
01Billing 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.
02Configure system to flag Bonscresa, Lerochol, Nufymco, and Oziltus as non-preferred requiring step therapy.
03Implement quantity limit validation for Bonscresa, Lerochol, Nufymco, and Zycubo.
04Update site of care requirements for all medications listed.
05Notify providers in writing of new requirements and access Clinical Criteria documents.
06Before August 1, 2026: Identify and contact patients currently receiving these medications without prior authorization to obtain retroactive authorization or notify of coverage changes.
If missed: Failure to obtain prior authorization will result in claim denials.

Codes mentioned

C9399J3590J3490J9999J1072Q5162Q5161J1951J9210J9256J0888J1809J3404J7174J1930J1932J3316

Original notice

[Ohio] Specialty pharmacy updates for May 2026
providernews.anthem.com · Always check the source before changing claims.
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Related changes

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[New York] Specialty pharmacy updates for May 2026MediumEffective Aug 1, 2026 · Pharmacy[Virginia] Specialty pharmacy updates for May 2026HighEffective Aug 1, 2026 · Pharmacy[Georgia] Specialty pharmacy updates for May 2026HighEffective Aug 1, 2026 · Pharmacy[New York] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · PharmacyBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesOH policy changesPharmacyOncologyEndocrinologyHematologyNephrologyOphthalmologyPediatricsCode C9399Code J3590Code J3490Code J9999Code J1072Code Q5162Code Q5161Code J1951Code J9210Code J9256Code J0888Code J1809Code J3404Code J7174Code J1930Code J1932Code J3316

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