Medicare AdvantagePrior AuthMedium impact
[New York] Expansion of the specialty pharmacy precertification list
Anthem BCBS·NY · Pharmacy, Oncology, Ophthalmology·Pharmacy
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Medicare Advantage in New York is adding five specialty pharmacy drugs to its precertification review process and implementing step therapy requirements for three of those drugs. Billing teams must obtain prior authorization for these Part B medications before dispensing, and step therapy will apply to new patients (but not those already receiving these medications).
Action Required
By June 15, 2026: Billing team must update prior authorization workflows to require precertification for all specialty pharmacy claims using HCPCS codes C9399, J3590, and J9999 for Anthem Medicare Advantage New York members. Pharmacy staff and providers must contact Anthem for prior auth before dispensing Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea. For Bonscresa, Nufymco, and Oziltus specifically, apply step therapy criteria per CC-0027 and CC-0072 guidelines (available at https://anthem.com/provider) during precertification review, except for patients already actively receiving these medications. Update billing system rules and provider communication materials. Claims submitted without required prior authorization will be denied. Verify member eligibility and plan type before applying these requirements, as they apply only to Anthem Medicare Advantage plans in New York.