MedicaidPrior AuthMedium impact
[New York] Prior authorization and step therapy updates
Anthem BCBS·NY · Oncology, Ophthalmology, Rheumatology +1 more·Provider Bulletin
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, six specialty pharmacy medications billed on medical claims now require prior authorization under New York Medicaid. Additionally, two of these drugs (Lerochol and Nufymco) are subject to new step therapy requirements that will be applied during prior authorization initiation or renewal.
Action Required
By May 31, 2026: Billing team must implement prior authorization requirements in billing system for the following medications billed on medical claims under New York Medicaid: Boncresa (denosumab-mobz), Lerochol (lerodalcibep-liga), Nufymco (ranibizumab-leyk), Oziltus (denosumab-mobz), Rybrevant Faspro (amivantamab + hyaluronidase-njft), and Yartemlea (narsopilmab-wuug). Additionally, configure system to flag Lerochol and Nufymco for step therapy review upon prior authorization initiation or renewal. Providers must verify National Drug Code (NDC) is included on all medical claims for these drugs. Update internal workflows and provider communication to alert staff that patients currently receiving these medications will require new prior authorization requests. Obtain prior authorization before claim submission or claims will be denied. Reference Clinical Criteria documents (CC-0027, CC-0299, CC-0072, CC-0201, CC-0298, CC-0297) for specific clinical criteria requirements via Anthem's Clinical Criteria website.