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Anthem BCBSMedicare Advantage · Prior Auth · Pharmacy · VA · Oncology, Rheumatology, Hematology +1 moreHigh impact

[Virginia] Specialty pharmacy precertification list expands

Act
by Jan 1, 2027
Effective date
Jan 1, 2027
Identified
Oct 14, 2026

Summary

Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage members. Effective January 1, 2027, step therapy precertification will apply to multiple Part B medications (denosumab, bendamustine, pemetrexed, and hyaluronate products). Additionally, effective February 1, 2027, three new specialty drugs (golimumab-sldi, bevacizumab-vikg, and isatuximab-irfc) will require precertification review. Noncompliance with these new requirements may result in claim denial.

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What to do

by Jan 1, 2027 · 4 steps
01Billing team must implement step therapy precertification review for Part B medications listed in Clinical Criteria Guidelines (CC-0027, CC-0310, CC-0116, CC-0094, CC-0005) in the billing system.
02Step therapy will apply upon initiation of precertification in addition to medical necessity review and will NOT apply to members already receiving these medications.
03By February 1, 2027: Billing team must update prior authorization workflows to require precertification for HCPCS codes C9399/J3590 (Immgolis Intri and Lytenava) and C9399/J9999 (Sarclisa Escena) for Anthem Medicare Advantage members in Virginia.
04Reference the Clinical Criteria Guidelines available on the Anthem provider website.
If missed: Failure to obtain required precertification may result in claim denial and member ineligibility for reimbursement.

Codes mentioned

C9399J3590J9999J9033J9034J9036J9056J9305J9314J9322J9323J9294J9296J9297J9304

Original notice

[Virginia] Specialty pharmacy precertification list expands
providernews.anthem.com · Always check the source before changing claims.
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Related changes

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[California] Specialty pharmacy precertification list expandsMediumNo effective date · Pharmacy[New York] Specialty pharmacy precertification list expandsHighEffective Jan 1, 2027 · Pharmacy[Ohio] Specialty pharmacy precertification list expandsHighEffective Jan 1, 2027 · Pharmacy[Georgia] Specialty pharmacy precertification list expandsMediumNo effective date · PharmacyBrowse every Anthem BCBS change in the policy list

Related policy hubs

Anthem BCBS policiesVA policy changesOncologyRheumatologyHematologyPharmacyCode C9399Code J3590Code J9999Code J9033Code J9034Code J9036Code J9056Code J9305Code J9314Code J9322Code J9323Code J9294Code J9296Code J9297Code J9304

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