MedicaidPrior AuthMedium impact
[Virginia] Medicaid providers: new PA and step therapy for specialty drugs — action required
Anthem BCBS·VA · Pharmacy, Oncology, Ophthalmology +1 more·Government Programs
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Virginia Medicaid (Anthem HealthKeepers) is implementing new prior authorization requirements for six specialty pharmaceutical drugs and adding step therapy review requirements for Nufymco. Billing teams must obtain prior authorization for these drugs on medical claims and include NDC codes for proper processing.
Action Required
By May 15, 2026: Billing team must implement prior authorization workflow for the following specialty drugs billed on medical claims: Boncresa (denosumab-mobz), Lerochol (lerodalcibep-liga), Nufymco (ranibizumab-leyk), Oziltus (denosumab-mobz), Rybrevant Faspro (amivantamab + hyaluronidase-njft), and Yartemlea (narsopilmab-wuug). Update billing system templates and provider encounter forms to: (1) flag these drugs for prior authorization initiation before claim submission, (2) require NDC code entry on all medical claims for these drugs, and (3) ensure step therapy requirements are checked for Nufymco renewals. Contact Anthem HealthKeepers through Availity Chat or provider website for Clinical Criteria details (CC-0027, CC-0299, CC-0072, CC-0201, CC-0298, CC-0297) before the effective date. Train clinical staff and providers on new requirements. Failure to obtain prior authorization will result in claim denials.