Medicare AdvantagePrior AuthHigh impact
[New York] Expansion of specialty pharmacy precertification list
Anthem BCBS·NY · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Medicare Advantage in New York is expanding its specialty pharmacy precertification requirements to include 9 new Part B drugs and implementing step therapy for Keytruda Qlex and Tecentriq Hybreza. All claims for these medications without proper precertification and step therapy compliance will be deemed ineligible for reimbursement.
Action Required
By May 31, 2026: Billing team must update precertification workflows and billing system rules to require prior authorization for all specialty pharmacy claims using codes C9399, J3590, J9999, J3490, and G2083 for Anthem Medicare Advantage members in New York. Implement step therapy requirements for Keytruda Qlex (pembrolizumab and berahyaluronidase alfa-pmph) and Tecentriq Hybreza (atezolizumab and hyaluronidase-tqjs), ensuring step therapy is not applied to members already receiving the non-preferred versions. Providers must initiate precertification before dispensing any of these 9 specialty drugs listed in the policy. Update encounter forms and staff training to identify these medications. Reference Clinical Criteria Guidelines (CC-0002, CC-0027, CC-0124, CC-0128) when submitting precertification requests. Non-compliance will result in claim denials and members may be held responsible for payment.