[Virginia] Specialty pharmacy updates, March 2026

By May 31, 2026: Billing team must update claims processing system to require prior authorization for all 8 specialty pharmacy drugs listed (Armlupeg, Blenrep, Exdensur, Jubereq, Osvyrti, Poherdy, Redemplo, Voyxact) when billed with HCPCS codes C9399, J3590, J9999, or J3490. For oncology uses (marked with *), route PA requests to Carelon Medical Benefits Management; for non-oncology uses, route to Anthem's medical specialty drug review team. Implement quantity limit controls in billing system for 8 drugs listed in quantity limit table. Establish step therapy workflows to designate Keytruda and Tecentriq as preferred, with Keytruda Qlex and Tecentriq Hybreza as non-preferred requiring step therapy. Train providers to include NDC codes on all specialty pharmacy claims to expedite processing. Access Clinical Criteria website (https://www.anthem.com/ms/pharmacyinformation/clinicalcriteria/home.html) for complete medical necessity documentation requirements. Notify patients currently on these medications that prior authorization will now be required for continued coverage. Failure to obtain prior authorization before June 1, 2026, will result in claim denials.