Medicare AdvantagePrior AuthMedium impact
[California] Expansion of the specialty pharmacy precertification list
Anthem BCBS·CA · Pharmacy, Oncology·Pharmacy
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Medicare Advantage in California is expanding its specialty pharmacy precertification requirements to include five new Part B drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea) and adding step therapy review to three of these medications. Prior authorization will now be required for all five drugs, and step therapy will apply to Bonscresa, Nufymco, and Oziltus unless members are already actively receiving them.
Action Required
By June 1, 2026: Billing team must update billing software and prior authorization workflows to require precertification for HCPCS codes C9399, J3590, and J9999 when billing for the five specified Part B drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea) for Anthem Medicare Advantage members in California. Implement step therapy precertification review for Bonscresa, Nufymco, and Oziltus per Clinical Criteria guidelines (CC-0027 and CC-0072). Providers must document active medication status to bypass step therapy requirements. Update encounter forms and clinical staff instructions to identify these medications and ensure prior auth is submitted before dispensing. Failure to obtain precertification will result in claim denials. Reference Anthem's Clinical Criteria guidelines at https://anthem.com/ca/provider for specific approval criteria.