Medicare AdvantagePrior AuthMedium impact
[Virginia] Expansion of the Specialty Pharmacy precertification list
Anthem BCBS·VA · Pharmacy, Oncology·Pharmacy
Effective date
Nov 1, 2026
We identified it
Jul 23, 2026
Summary
Effective November 1, 2026, Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia are expanding their specialty pharmacy precertification requirements to include two new Medicare Part B drugs: Decnupaz (pivekimab sunirine-pvzy) and Lumvoa (veligrotug-vvze). Billing teams must implement prior authorization workflows for these medications or face claim denials.
Action Required
By October 31, 2026: Billing team must update the EHR/billing system to flag claims for HCPCS codes J9999, C9399, C9339, and J3590 as requiring precertification before submission to Anthem Blue Cross and Blue Shield Medicare Advantage plans in Virginia. Add these codes to the prior authorization checklist in the pharmacy workflow. Clinical staff must obtain precertification approval from Anthem before dispensing or administering Decnupaz or Lumvoa to Virginia Medicare Advantage patients. Update pharmacy and provider documentation templates to identify these medications. Failure to obtain required precertification will render claims ineligible for reimbursement.