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Anthem BCBSCommercial · Prior Auth · Pharmacy · VA · Oncology, Hematology, PharmacyHigh impact

[Virginia] Specialty pharmacy updates — July 2026

Act
by Jul 1, 2026
Effective date
Jul 1, 2026
Identified
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.

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What to do

by Jul 1, 2026 · 9 steps
01Billing 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).
02Update billing software to flag these codes for mandatory prior authorization before claim submission.
03For Filkri and Ponlimsi, configure system to treat as non-preferred with step therapy requirements.
04Apply quantity limits for Avlayah and Ponlimsi.
05For oncology uses of Filkri and Ponlimsi, route authorization requests to Carelon Medical Benefits Management.
06Providers must document medical necessity with all prior authorization submissions.
07Claims submitted without prior authorization will be denied.
08Additionally, 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.
09Train billing staff on new workflows and access Availity for payer communication.

Codes mentioned

C9399J3590

Original notice

[Virginia] Specialty pharmacy updates — July 2026
providernews.anthem.com · Always check the source before changing claims.
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Related changes

See all Anthem BCBS changes →
[New York] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Ohio] Specialty pharmacy updates — November 2026HighEffective Feb 1, 2027 · Pharmacy[Virginia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · Pharmacy[Georgia] Specialty pharmacy updates — November 2026HighEffective Nov 1, 2026 · PharmacyBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesVA policy changesOncologyHematologyPharmacyCode C9399Code J3590

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