CommercialPrior AuthHigh impact
[Virginia] Specialty pharmacy updates — July 2026
Anthem BCBS·VA · Oncology, Pharmacy·Pharmacy
Effective date
Oct 1, 2026
We identified it
Jun 27, 2026
Summary
Effective October 1, 2026, Anthem Blue Cross and Blue Shield is implementing new step therapy requirements for specialty pharmacy medications in Virginia. Nivolumab (Opdivo) products will now require prior authorization review before patients can continue receiving these medications, even if they are currently on therapy without prior authorization.
Action Required
By September 30, 2026: Billing and clinical teams must implement prior authorization requirements for Opdivo (nivolumab, HCPCS J9299) and Qvantig (nivolumab hyaluronidase-nvhy, HCPCS J9289) in the Anthem specialty pharmacy billing system. Update all encounter templates, prior authorization workflows, and provider communication systems to flag these medications for step therapy review. Notify all oncology providers that patients currently receiving these medications without prior authorization will require prior auth approval for continued coverage on or after October 1, 2026. Failure to obtain prior authorization will result in claim denials and potential coverage gaps for patients. Reference Anthem Clinical Criteria CC-0125 (preferred) and CC-0281 (non-preferred) for medical necessity documentation requirements.