MedicaidPrior AuthMedium impact
[Ohio] Action needed: Medicaid providers — PA required for certain medical benefit drugs
Anthem BCBS·OH · Infectious Disease, Internal Medicine, Family Medicine·Government Programs
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Blue Cross and Blue Shield Ohio Medicaid now requires prior authorization for Sunlenca (lenacapavir) injection and tablet when billed on medical claims. Providers must request PA approval before dispensing continued use of this HIV antiretroviral medication. The National Drug Code (NDC) must be included on all medical claims for processing.
Action Required
By May 15, 2026: Billing team must implement prior authorization requirement for Sunlenca (lenacapavir) in the billing system and EMR for all Ohio Medicaid patients. Update clinical staff to request PA through Availity or direct payer contact before patients continue receiving this medication. Ensure all claims include the NDC code. Communicate policy change to prescribing providers. Claims submitted without prior authorization after June 1, 2026 will be denied.