Medicare AdvantagePrior AuthMedium impact
[California] Anthem expands specialty pharmacy precertification list
Anthem BCBS·CA · Oncology, Ophthalmology, Allergy & Immunology +1 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include 11 new Medicare Part B drugs (primarily denosumab biosimilars, immune globulins, and select oncology/ophthalmology agents). Additionally, step therapy review will be applied to these medications upon precertification initiation. Claims submitted without proper precertification will be denied.
Action Required
By April 15, 2026: Billing team and clinical staff must implement precertification requirements for all claims with HCPCS codes C9399, J3590, J3490, and J9999 when billed for Anthem Medicare Advantage California members. Update billing system to require prior authorization initiation before claim submission for the 11 listed specialty drugs. Educate prescribers that step therapy criteria (per Clinical Criteria Guidelines CC-0027, CC-0072, CC-0003) will be evaluated during precertification review; exceptions apply only to members actively receiving these medications. Update provider encounter templates to include precertification checklist. Designate staff member to monitor Anthem's Clinical Criteria Guidelines page for specific step therapy requirements. Failure to obtain precertification will result in claim denials.