MedicaidPrior AuthHigh impact
[Virginia] Prior authorization and step therapy updates
Anthem BCBS·VA · Oncology, Hematology, Rheumatology·Provider Bulletin
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, eight specialty pharmacy drugs billed under Virginia Medicaid medical benefits will require prior authorization. Additionally, four immunotherapy drugs (Keytruda, Keytruda Qlex, Tecentriq, and Tecentriq Hybreza) will be subject to new step therapy review requirements upon prior authorization initiation or renewal. Claims must include NDC codes and reference the appropriate Clinical Criteria documents.
Action Required
By April 30, 2026: Billing team must implement prior authorization requirements for all specialty pharmacy drugs billed on medical claims for Virginia Medicaid patients. (1) Update billing system to trigger prior authorization requests for: Armlupeg (pegfilgrastim-unne), Blenrep (belantamab mafodotin-blmf), Exdensur (depemokimab-ulaa), Jubereq (denosumab-desu), Osvyrti (denosumab-desu), Poherdy (pertuzumab-dpzb), Redemplo (plozasiran), and Voyxact (sibeprenlimab-szsi). (2) Ensure all medical claims include NDC codes for these medications. (3) For Keytruda, Keytruda Qlex, Tecentriq, and Tecentriq Hybreza: implement step therapy review processes upon prior authorization initiation or renewal in addition to medical necessity review. (4) Providers must reference the applicable Clinical Criteria documents (CC-0002, CC-0295, CC-0043, CC-0027, CC-0110, CC-0294, CC-0296, CC-0124, CC-0128) when submitting prior authorization requests via Availity. Claims will be denied without proper prior authorization and step therapy compliance.