Medicare AdvantagePrior AuthHigh impact
[Ohio] Anthem expands specialty pharmacy precertification list
Anthem BCBS·OH · Oncology, Rheumatology, Ophthalmology +2 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem is expanding its specialty pharmacy precertification list for Medicare Advantage members in Ohio. Ten specialty Part B drugs now require prior authorization, and six denosumab biosimilars plus one aflibercept product require step therapy review before approval. Billing teams must update systems to require precertification for these medications to avoid claim denials.
Action Required
By April 30, 2026: Billing team must update billing system to flag all claims with HCPCS codes C9399, J3590, J3490, and J9999 when billed for the following Medicare Part B drugs: Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Xtrenbo, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, and Qivigy. Require prior authorization submission before claim submission. For denosumab and aflibercept products, add step therapy verification requirement using Clinical Criteria Guidelines (CC-0027 for denosumab biosimilars, CC-0072 for Eydenzelt, CC-0003 for immune globulins) — step therapy does not apply to members actively receiving these medications. Notify providers and prior auth staff of the new requirements. Update precertification submission workflows to reference the Anthem Clinical Criteria Guidelines. Failure to obtain precertification will result in claim denials for Ohio Medicare Advantage members.