CommercialPrior AuthHigh impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem BCBS·VA · Oncology, Hematology, Infectious Disease +3 more·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements, quantity limits, and updated clinical criteria for specialty pharmacy drugs effective October 1, 2026. Four drugs now require prior authorization (Fesilty, Loargys, Vykoura, and Leucovorin calcium), two drugs are subject to quantity limits (Loargys and Yuviwel), and eight clinical criteria documents have been updated that may result in previously covered services being denied as not medically necessary. Billing teams must begin requesting prior authorizations for affected specialty pharmacy claims and ensure NDC codes are included on claims using NOC billing codes.
Action Required
By September 15, 2026: Billing team must update billing system to require prior authorization for specialty pharmacy drugs billed with HCPCS codes C9399, J3590, and J3490 when associated with clinical criteria CC-0149, CC-0301, CC-0104, and CC-0300. For claims using Not Otherwise Classified (NOC) codes, ensure National Drug Code (NDC) codes are included on all claims to expedite processing. Clinical staff must review updated clinical criteria documents (CC-0003, CC-0058, CC-0065, CC-0104, CC-0124, CC-0128, CC-0142, CC-0236) at https://anthem.com/provider and prepare for potential denials of previously covered immunoglobulin, octreotide, hemophilia, immunotherapy, and somatostatin analog services. Providers must understand that oncology prior authorizations are managed by Carelon Medical Benefits Management (separate from Anthem's medical specialty drug review team). Implement quantity limit controls in billing system for Loargys and Yuviwel. Failure to obtain prior authorization before October 1, 2026, will result in claim denials for specialty pharmacy medications.