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[Virginia] Quarterly pharmacy formulary change notice — Cardinal Care Medicaid

Anthem BCBS·VA · Pharmacy, Oncology, Cardiology +7 more·Pharmacy
Effective date
Aug 1, 2026
We identified it
Aug 12, 2026
Days to comply

Summary

Anthem HealthKeepers Plus (Cardinal Care Medicaid) in Virginia is implementing significant pharmacy formulary and utilization management changes effective August 1, 2026. Multiple medications are moving to preferred status, being added to formulary, or having prior authorization and quantity limit edits added, removed, or modified. Billing teams must identify affected prescriptions, update prior authorization workflows, and communicate transition requirements to providers and patients.

Action Required

Action needed
By July 31, 2026: (1) Billing team must update pharmacy billing system to reflect all formulary status changes listed in the policy table (medications moving to PREFERRED, COVERED, or with new/removed PA requirements). (2) Create a reference guide mapping all medications with NEW prior authorization requirements (e.g., Nuzolvence, Lunsumio, Rybrevant, Jobevne, Vykoura, Cardamyst, Myqorzo, Loargys, Yuviwel, Aqvesme, Yartemlea, Zycubo, Daybue, Yuvezzi) and medications with REMOVED PA requirements (e.g., Doxorubicin injection, Iron supplements: Feraheme, Ferrlecit, Venofer, Infed, Injectafer, Monoferric). (3) Update PA submission templates in your billing software to require PA for all newly restricted medications before claim submission. (4) For medications with REMOVED PA or QL (e.g., Cranberry, Loreev XR, Pepto-Bismol, Eucerin, Pedialyte, Colace, Fibercon, saline nasal sprays, etc.), remove PA/QL blocks from billing system to prevent claim rejections. (5) Coordinate with clinical staff to identify patients currently on non-preferred or PA-restricted medications and initiate transition discussions to preferred alternatives listed in the policy or arrange prior authorizations before August 1. (6) Train billing staff on new quantity limits added to medications (e.g., Diazepam 8 ML/day, Lorazepam 10 syringes/30 days, Midazolam 10 auto-injectors/30 days, Nuzolvence 1 kit per 30 days, Ranitidine 2 tablets/day or 1 tablet/day depending on strength). (7) Contact Anthem HealthKeepers Plus Pharmacy Department at 800-901-0020 for any clarification on specific medication transitions. Claims submitted without required prior authorization for restricted medications or exceeding quantity limits will be denied. Consequences of inaction include claim denials, patient out-of-pocket costs, and potential service disruptions.