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[Virginia] Specialty pharmacy updates
Act
by Nov 15, 2026
Effective date
Dec 1, 2026
Identified
Sep 2, 2026
Summary
Anthem Blue Cross and Blue Shield (Virginia) is implementing new prior authorization requirements for 5 specialty pharmacy drugs effective December 1, 2026, adding quantity limits for 3 of those drugs, and revising clinical criteria for 11 existing specialty medications. Patients currently receiving these medications without prior authorization will require prior auth requests going forward. Inclusion of NDC codes on claims will expedite processing for drugs billed with NOC codes.
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What to do
by Nov 15, 2026 · 6 steps
01Billing team must update billing system to require prior authorization for all claims with HCPCS codes C9399, J3590, and J9999 dated on or after December 1, 2026.
02For the following drugs, implement quantity limit edits in billing system: Saphnelo Autoinjector (anifrolumab-fnia), Lumvoa (veligrotug-vvze), and Trutakna (atacicept).
03Clinical staff must review Anthem's updated Clinical Criteria documents (CC-0202, CC-0303, CC-0304, CC-0305, CC-0306, CC-0057, CC-0077, CC-0099, CC-0112, CC-0119, CC-0125, CC-0162, CC-0237, CC-0243, CC-0276, CC-0281) to understand new medical necessity requirements.
04Providers must begin documenting additional medical necessity information in patient records for all specialty pharmacy claims to support prior authorization requests.
05For oncology use of Decnupaz (pivekimab sunirine-pvzy), route prior authorization requests to Carelon Medical Benefits Management, not Anthem's medical specialty drug review team.
06For all specialty pharmacy claims, ensure NDC codes are included on claims to expedite processing when NOC codes are billed.
If missed: Failure to obtain required prior authorization or meet quantity limits will result in claim denials or delays.
Codes mentioned
C9399J3590J9999
Original notice
[Virginia] Specialty pharmacy updates
providernews.anthem.com · Always check the source before changing claims.
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