CommercialPrior AuthHigh impact
[Virginia] Specialty pharmacy updates for May 2026
Anthem BCBS·VA · Oncology, Hematology, Endocrinology +3 more·Pharmacy
Effective date
Aug 1, 2026
We identified it
May 3, 2026
Summary
Effective August 1, 2026, Anthem Virginia is implementing prior authorization, quantity limits, step therapy, and site of care requirements for 13 specialty pharmacy medications. Billing teams must update systems to require prior authorization for these drugs before dispensing and verify medical necessity documentation. Patients currently receiving these medications without prior auth will need authorization for continued coverage.
Action Required
By July 15, 2026: Billing team must update Anthem claim submission processes and prior authorization workflows to require prior auth submission for all specialty pharmacy medications listed (Bonscresa, Lerochol, Nufymco, Oziltus, Rybrevant Faspro, Yartemlea, Zycubo, and site-of-care drugs including Azmiro, Bildyos, Bosaya, Fensolvi, Gamifant, Imaavy, Mircera, Nulibry, Papzimeos, Qfitlia, Somatuline Depot, and Triptodur) effective August 1, 2026. Providers and pharmacy staff must: (1) Review Clinical Criteria documents for each drug via Anthem's portal, (2) Submit prior authorization requests before dispensing for dates of service on or after 8/1/26, (3) Document medical necessity on all requests as some medications require additional documentation, (4) Flag non-preferred medications (Bonscresa, Lerochol, Nufymco, Oziltus) for step therapy review, (5) Apply quantity limits during claim entry for applicable drugs. Update encounter templates and pharmacy systems to prompt for prior auth. Claims submitted without required prior authorization will be denied. Coordinate with specialty pharmacies and providers to notify patients currently on these medications that authorization may be needed for continued coverage.