MedicaidPrior AuthHigh impact
[California] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·CA · Ophthalmology, Oncology, Rheumatology +8 more·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross (California Medicaid) is adding 80+ specialty pharmacy medications to its prior authorization requirements when billed under the medical benefit, and implementing step therapy reviews for specific drugs. Providers must now obtain prior authorization before dispensing these medications and include NDC codes on all medical claims for these drugs.
Action Required
By June 30, 2026: Billing team must (1) Update billing system to require prior authorization for all 80+ specialty pharmacy drugs listed in the policy before processing medical claims; (2) Create internal workflow checklist mapping each drug name to its Clinical Criteria code (CC-0027, CC-0072, CC-0043, etc.) for PA requests; (3) Train providers and staff that patients currently receiving these medications without PA will require PA initiation/renewal as of July 1, 2026; (4) Ensure all medical claims for these drugs include valid NDC codes in billing records; (5) For step therapy drugs (e.g., aflibercept variants, bevacizumab variants, ranibizumab variants, mepolizumab, ustekinumab variants), configure system to apply step therapy review at PA initiation or renewal in addition to medical necessity review, noting preferred vs. non-preferred status per the policy table. Immediately contact Anthem via Availity Chat or provider website to confirm PA submission process and obtain updated Clinical Criteria documents. Failure to obtain prior authorization will result in claim denials for dates of service on or after July 1, 2026.