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[New York] Specialty pharmacy updates for May 2026
Act
by Jul 15, 2026
Effective date
Aug 1, 2026
Identified
May 3, 2026
Summary
Effective August 1, 2026, Anthem Blue Cross specialty pharmacy policies are changing for New York commercial plans. Seven specialty drugs now require prior authorization, quantity limits, step therapy reviews, or site of care determinations. Billing teams must implement these requirements in their systems to avoid claim denials for patients currently receiving these medications without prior auth.
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What to do
by Jul 15, 2026 · 7 steps
01Billing team must update billing software and prior authorization workflows to reflect new Anthem specialty pharmacy requirements for New York commercial plans.
02Add the following drugs to prior auth requirement matrix: Bonscresa, Lerochol, Nufymco, Oziltus, Rybrevant Faspro, Yartemlea, and Zycubo with associated HCPCS codes (C9399, J3590, J3490, J9999).
03Configure quantity limits for Bonscresa, Lerochol, Nufymco, Oziltus, and Zycubo.
04Mark Bonscresa, Lerochol, Nufymco, and Oziltus as non-preferred for step therapy review.
05Set site of care requirements for testosterone cypionate, denosumab biosimilars, leuprolide, emapalumab, nipocalimab, epoetin beta, fosdenopterin, zopapogene, fitusiran, and lanreotide.
06Notify providers to expect prior auth requests starting August 1, 2026 for patients currently on these medications.
07Verify Carelon Medical Benefits Management processes for oncology use medications (marked with *).
If missed: Failure to implement these controls will result in claim denials for affected specialty pharmacy medications.
Codes mentioned
C9399J3590J3490J9999J1072Q5162Q5161J1951J9210J9256J0888J1809J3404J7174J1930J1932J3316
Original notice
[New York] Specialty pharmacy updates for May 2026
providernews.anthem.com · Always check the source before changing claims.
Related changes
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