MedicaidPrior AuthMedium impact
[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·VA·Provider Bulletin
Effective date
Jul 1, 2026
We identified it
May 21, 2026
Summary
Effective July 1, 2026, four specialty pharmacy drugs billed under the medical benefit for Virginia Medicaid now require prior authorization: Fesilty (fibrinogen, human-chmt), Loargys (pegzilarginase-nbln), Vykoura (leucovorin calcium), and Yuviwel (navepegritide). Billing teams must obtain prior authorization before claims are submitted for these medications, and National Drug Codes (NDCs) must be included on all medical claims for processing.
Action Required
By June 30, 2026: Billing team must implement prior authorization requirements for four specialty pharmacy drugs (Fesilty, Loargys, Vykoura, Yuviwel) billed under medical benefits for Virginia Medicaid patients. Update billing software and provider encounter forms to flag these medications and trigger prior authorization workflow before claim submission. Ensure all claims for these drugs include National Drug Codes (NDCs). Providers should reference the Clinical Criteria website (Clinical Criteria CC-0149, CC-0301, CC-0104, CC-0300) for specific approval requirements. Contact HealthKeepers via Availity Chat or provider website for authorization questions. Failure to obtain prior authorization will result in claim denials for these medications.