Medicare AdvantagePrior AuthHigh impact
[Virginia] Expansion of specialty pharmacy precertification list
Anthem BCBS·VA · Oncology, Hematology, Internal Medicine +1 more·Pharmacy
Effective date
Jun 1, 2026
We identified it
May 3, 2026
Summary
Effective June 1, 2026, Anthem Blue Cross Blue Shield Virginia is expanding its specialty pharmacy precertification requirements to include 9 new Medicare Part B drugs and implementing step therapy review for pembrolizumab and atezolizumab variants. Billing teams must obtain precertification for these drugs before claims submission, and step therapy will apply to new patients (not current users). Noncompliance will result in claim denials.
Action Required
By May 31, 2026: Billing team and providers must implement precertification workflow for all claims using HCPCS codes C9399, J3590, J9999, J3490, and G2083 for Anthem Blue Cross Blue Shield Virginia Medicare Advantage members. Update billing system to flag the following drugs for mandatory prior authorization before submission: Armlupeg, Blenrep, Exdensur, Jubereq, Osvyrti, Poherdy, Redemplo, and Spravato. For Keytruda Qlex and Tecentriq Hybreza, implement step therapy precertification requirements—these will apply only to new patients; exempt members already receiving Keytruda or Tecentriq. Verify patient eligibility and step therapy status during precertification initiation. Add Clinical Criteria Guideline reference (CC-0002, CC-0027, CC-0124, CC-0128) documentation to precertification requests. Educate providers that claims submitted without precertification approval will be deemed ineligible for reimbursement. Consult Clinical Criteria Guidelines at the provider website for specific coverage criteria.