Medicare AdvantagePrior AuthMedium impact
[Ohio] Expansion of the specialty pharmacy precertification list
Anthem BCBS·OH · Pharmacy, Oncology, Ophthalmology·Pharmacy
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification list to include 5 Medicare Part B drugs that will now require prior authorization and step therapy review. Billing teams must update systems to require precertification for these drugs before claims are submitted to avoid denials.
Action Required
By June 15, 2026: Billing team must update billing software to require prior authorization for all claims with HCPCS codes C9399, J3590, and J9999 when associated with the five specialty drugs listed (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea). Providers and clinical staff must initiate precertification requests before dispensing these medications. Update encounter templates and order entry systems to flag these drugs for prior auth. Additionally, implement step therapy screening during precertification initiation per Clinical Criteria guidelines (CC-0027 and CC-0072) available at https://anthem.com/provider. Claims submitted without prior authorization will be denied. NOTE: Step therapy does not apply to members already actively receiving these medications.