CommercialPrior AuthHigh impact
[Virginia] Specialty pharmacy updates — February 2026
Anthem BCBS·VA · Oncology, Hematology, Rheumatology +3 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 18, 2026
Summary
Anthem Blue Cross Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for 13 specialty pharmacy drugs effective May 1, 2026. Patients currently receiving these medications without prior authorization will require PA review going forward. Billing teams must update systems to request prior authorization for these specialty drugs and include NDC codes on claims to expedite processing.
Action Required
By April 30, 2026: Billing team must update billing system configuration to require prior authorization for all specialty pharmacy claims using codes C9399, J3590, J3490, and J9999 when billed for the 13 drugs listed (Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, Qivigy, Radicava, and Xtrenbo). Providers must begin submitting prior authorization requests before May 1, 2026 for any patients currently on these medications. Billing team should configure system to enforce quantity limits for the specified drugs and apply step therapy edits marking immune globulin and denosumab products as non-preferred. Ensure NDC codes are included on all claims to expedite processing. For oncology-indicated drugs, route prior authorization requests to Carelon Medical Benefits Management, Inc. rather than Anthem directly. Failure to obtain prior authorization will result in claim denials. Reference Clinical Criteria document (CC-0003, CC-0027, CC-0049, CC-0072, CC-0124, CC-0292, CC-0293) for specific medical necessity requirements.