CommercialPrior AuthHigh impact
[New York] Clinical Criteria updates for specialty pharmacy
Anthem BCBS·NY · Oncology, Hematology, Endocrinology +3 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jun 13, 2026
Summary
Anthem Blue Cross Blue Shield New York is implementing new clinical criteria for three specialty pharmacy drugs and revising criteria for seven existing drugs, which may result in previously covered services now being deemed not medically necessary. The changes affect both oncology and non-oncology specialty drugs with different review teams managing each category.
Action Required
By July 1, 2026: Billing team must review and update prior authorization processes for specialty pharmacy drugs including Colony Stimulating Factor Agents, Denosumab Agents, Monoclonal Antibodies to Interleukin-5, Strensiq, Pertuzumab Agents, Darzalex products, and Tryngolza. Verify coverage criteria at Clinical Criteria in Pharmacy portal before prescribing. Alert providers that revised criteria may result in denials for previously covered services. Update encounter forms to distinguish between oncology drugs (managed by Carelon) and non-oncology specialty drugs (managed by Anthem Medical Specialty Drug Review team).