Medicare AdvantagePrior AuthHigh impact
[Ohio] Expansion of specialty pharmacy precertification list
Anthem BCBS·OH · Oncology, Hematology, Pharmacy +1 more·Pharmacy
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Blue Cross and Blue Shield (Ohio) is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and implementing step therapy review for specific immunotherapy medications. Billing teams must obtain precertification for these drugs before dispensing and apply step therapy protocols for Keytruda Qlex and Tecentriq Hybreza, except for members already actively receiving the original preferred formulations.
Action Required
By May 31, 2026: Billing team must update prior authorization protocols in billing system to require precertification for all specialty pharmacy claims using HCPCS codes C9399, J3590, J9999, J3490, and G2083 for Medicare Advantage members in Ohio. Implement step therapy review process in prior authorization workflow for Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) and Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs) per Clinical Criteria Guidelines CC-0124 and CC-0128. Ensure system flags that step therapy does NOT apply to members already actively receiving original Keytruda or Tecentriq formulations. Train providers and prior authorization staff on new requirements. Update encounter forms and prior authorization request templates to identify when these drugs are being prescribed. Establish workflow to verify Clinical Criteria Guidelines on Anthem's provider website before submitting precertification. Notify clinical staff that noncompliance with precertification requirements will result in claim denials and ineligibility for reimbursement.