MedicaidPrior AuthHigh impact
[Ohio] Prior authorization and step therapy updates
Anthem BCBS·OH · Pharmacy, Pulmonology, Hematology +1 more·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid is adding 8 specialty pharmacy drugs to prior authorization requirements and implementing step therapy reviews for 8 medications (both preferred and non-preferred formulations). Billing teams must obtain prior authorization for these medications before dates of service and include NDC codes on all medical claims to avoid denials.
Action Required
By April 30, 2026: Billing team must update prior authorization workflows and EMR/billing system rules to require prior authorization initiation for the following specialty pharmacy drugs billed on medical claims: Armlupeg (pegfilgrastim-unne), Blenrep (belantamab mafodotin-blmf), Exdensur (depemokimab-ulaa), Jubereq (denosumab-desu), Osvyrti (denosumab-desu), Poherdy (pertuzumab-dpzb), Redemplo (plozasiran), and Voyxact (sibeprenlimab-szsi). For step therapy medications (Cinqair, Exdensur, Fasenra, Keytruda, Keytruda Qlex, Nucala, Tecentriq, Tecentriq Hybreza), implement step therapy review at prior authorization initiation or renewal in addition to medical necessity review using the specified Clinical Criteria codes (CC-0043, CC-0124, CC-0128). Ensure all medical claims include NDC codes for these drugs or claims will be denied. Providers and billing staff must review the Clinical Criteria website for specific authorization requirements. Update encounter templates and pre-authorization checklists to flag these medications. Contact Anthem through Availity Chat or provider line with questions about individual prior authorization requests.