[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit

By September 30, 2026: Billing team must implement prior authorization requirements for medications billed under medical claims for Avlayah (tividenofusp alfa-eknm, CC-0302), Filkri (filgrastim-laha, CC-0002), and Ponlimsi (denosumab-adet, CC-0027) when servicing Virginia Medicaid patients (HealthKeepers, Inc./Anthem HealthKeepers Plus). Providers must ensure NDC codes are included on all medical claims for these drugs. Update billing system workflows to require prior authorization requests before claim submission. For Opdivo (nivolumab, CC-0125) and Opdivo Qvantig (nivolumab hyaluronidase-nvhy, CC-0281), implement step therapy review requirements in addition to current medical necessity review at prior authorization initiation or renewal. Train billing and clinical staff on new requirements. Failure to obtain prior authorization or complete step therapy review will result in claim denials.