Medicare AdvantagePrior AuthMedium impact
[Virginia] Expansion of Specialty Pharmacy precertification list
Anthem BCBS·VA · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are adding two specialty Medicare Part B drugs (Filkri and Ponlimsi) to their precertification review process. These medications will also be subject to step therapy requirements in addition to medical necessity reviews, except for members already receiving these drugs.
Action Required
By September 30, 2026: Billing team must update authorization workflows to require precertification for HCPCS codes C9399 and J3590 (Filkri and Ponlimsi) for all Anthem Medicare Advantage members in Virginia. Prior to submitting claims for these medications, obtain precertification that includes step therapy review per Clinical Criteria Guidelines CC-0002 and CC-0027. Update encounter forms and billing software to flag these drugs as requiring prior auth. Note: Step therapy will not apply to members already actively receiving these medications. Failure to obtain precertification will result in claim denials. Reference Anthem's Clinical Criteria Guidelines and use Availity Chat with Payer for authorization questions.