Medicare AdvantagePrior AuthMedium impact
[New York] Anthem expands specialty pharmacy precertification list
Anthem BCBS·NY · Oncology, Allergy & Immunology, Pharmacy·Pharmacy
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem is expanding its specialty pharmacy precertification requirements for Medicare Advantage members in New York. Eleven specialty Part B drugs now require prior authorization, and nine denosumab/immune globulin products are subject to new step therapy requirements under specific clinical guidelines.
Action Required
By April 30, 2026: Billing and clinical teams must implement precertification requirements for all claims with HCPCS codes C9399, J3590, J3490, and J9999 when billed to Anthem Medicare Advantage in New York. (1) Update billing system to flag the 11 specialty drugs listed (Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Xtrenbo, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, Qivigy) for mandatory prior authorization before claim submission. (2) For the nine drugs with step therapy requirements (all denosumab products and immune globulin products listed), configure system to initiate step therapy review concurrent with medical necessity review; exempt members currently on these medications from step therapy. (3) Providers and clinical staff must reference Anthem's Clinical Criteria Guidelines (CC-0027 for denosumab products, CC-0072 for aflibercept, CC-0003 for immune globulins) at precertification initiation. (4) Update encounter forms and clinical workflows to ensure providers document medical necessity and treatment history. Noncompliance will result in claim denials. Reference Anthem's Clinical Criteria page and publication MULTI-BCBS-CR-002030-25-GRP791 for detailed guidelines.