MedicaidPrior AuthMedium impact
[Virginia] Prior authorization and step therapy updates for medications billed under the medical benefit
Anthem BCBS·VA · Infectious Disease, Rheumatology, Internal Medicine·Provider Bulletin
Effective date
Nov 1, 2026
We identified it
Sep 15, 2026
Summary
Effective November 1, 2026, five specialty pharmacy drugs billed under the medical benefit for Virginia Medicaid (HealthKeepers, Inc./Anthem HealthKeepers Plus) will now require prior authorization. These medications—Decnupaz, Hepcludex, Lumvoa, Saphnelo Autoinjector, and Trutakna—currently may not require authorization, but providers must obtain approval before continued patient use. National Drug Codes (NDCs) must be included on all medical claims for these drugs.
Action Required
By October 31, 2026: Billing team must implement prior authorization requirements for the following specialty medications billed on medical claims for Virginia Medicaid patients: Decnupaz (pivekimab sunirine-pvzy), Hepcludex (bulevirtide-gmod), Lumvoa (veligrotug-vvze), Saphnelo Autoinjector (anifrolumab-fnia), and Trutakna (atacicept). Update billing system workflows to flag these drugs and require prior auth review before claim submission. Ensure all medical claims for these medications include the National Drug Code (NDC). Providers should review Clinical Criteria document CC-0304, CC-0303, CC-0305, CC-0202, and CC-0306 for specific authorization criteria. Use Availity Chat with Payer during business hours for authorization questions and support. Failure to obtain prior authorization will result in claim denials.