Medicare AdvantagePrior AuthMedium impact
[Virginia] Expansion of the specialty pharmacy precertification list
Anthem BCBS·VA · Oncology, Ophthalmology, Rheumatology +1 more·Pharmacy
Effective date
Jul 1, 2026
We identified it
May 3, 2026
Summary
Effective July 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification list to include five Medicare Part B drugs (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, and Yartemlea) that now require prior authorization. Additionally, three of these drugs (Bonscresa, Nufymco, and Oziltus) will be subject to step therapy review in addition to medical necessity review.
Action Required
By June 15, 2026: Billing and clinical teams must update prior authorization workflows to require precertification for all claims using HCPCS codes C9399, J3590, and J9999 for the five specialty drugs listed (Bonscresa, Nufymco, Oziltus, Rybrevant Faspro, Yartemlea) when billed to Anthem Medicare Advantage Virginia members. Providers must implement step therapy requirements for Bonscresa, Nufymco, and Oziltus per Clinical Criteria guidelines CC-0027 and CC-0072 (available at https://anthem.com/provider). Update internal communication to providers and staff noting step therapy does not apply to members actively receiving these medications. Failure to obtain prior authorization will result in claim denials per Anthem policy.