Medicare AdvantagePrior AuthMedium impact
[California] Expansion of Specialty Pharmacy Precertification List
Anthem BCBS·CA · Oncology, Hematology, Pharmacy +1 more·Pharmacy
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include 8 new Medicare Part B drugs and implementing step therapy review for Keytruda Qlex and Tecentriq Hybreza. Precertification must be obtained before dispensing these medications, and step therapy will apply as an additional layer of review during precertification initiation. Noncompliance will result in claim denials.
Action Required
By May 31, 2026: Billing and prior authorization teams must update systems and workflows to require precertification for the 8 newly listed specialty pharmacy drugs (Armlupeg, Blenrep, Exdensur, Jubereq, Osvyrti, Poherdy, Redemplo, and Spravato) using HCPCS codes C9399, J3590, J9999, J3490, and G2083. Additionally, implement step therapy review requirements for Keytruda Qlex and Tecentriq Hybreza alongside standard medical necessity review, while ensuring Keytruda and Tecentriq remain preferred without step therapy. Update clinical criteria guidelines in billing system to reference CC-0002, CC-0027, CC-0124, and CC-0128. Train clinical staff and providers on new step therapy procedures. Before June 1, 2026, confirm that the billing system will deny claims for these medications without prior authorization. Verify that members actively receiving the step therapy medications are exempt from step therapy requirements.