CommercialPrior AuthHigh impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem BCBS·VA · Oncology, Hematology, Pharmacy·Pharmacy
Effective date
Jul 1, 2026
We identified it
Jun 26, 2026
Summary
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization, quantity limit, and step therapy requirements for three specialty pharmacy medications effective July 1, 2026, with additional clinical criteria revisions effective October 1, 2026. Patients currently receiving these medications without prior authorization will require approval going forward, and certain previously covered services may now be deemed not medically necessary under revised clinical criteria.
Action Required
By July 1, 2026: Billing and authorization teams must implement prior authorization requirements for specialty pharmacy claims using HCPCS codes C9399 and J3590 for the following medications: Avlayah (tividenofusp alfa-eknm), Filkri (filgrastim-laha), and Ponlimsi (denosumab-adet). Update billing software to flag these codes for mandatory prior authorization before claim submission. For Filkri and Ponlimsi, configure system to treat as non-preferred with step therapy requirements. Apply quantity limits for Avlayah and Ponlimsi. For oncology uses of Filkri and Ponlimsi, route authorization requests to Carelon Medical Benefits Management. Providers must document medical necessity with all prior authorization submissions. Claims submitted without prior authorization will be denied. Additionally, before October 1, 2026, review and update coverage criteria in billing system for the 15 revised Clinical Criteria drugs (including Keytruda, Bevacizumab, Imfinzi, Trodelvy, and others) as previously covered services may now be denied as not medically necessary. Train billing staff on new workflows and access Availity for payer communication.