Medicare AdvantagePrior AuthMedium impact
[Virginia] Anthem expands specialty pharmacy precertification list
Anthem BCBS·VA · Oncology, Ophthalmology, Allergy & Immunology +1 more·Pharmacy
Effective date
May 1, 2026
We identified it
May 3, 2026
Summary
Effective May 1, 2026, Anthem Blue Cross and Blue Shield (Virginia) is expanding its specialty pharmacy precertification requirements for Medicare Advantage plans. Eleven specialty Part B drugs now require prior authorization, and six denosumab biosimilars plus aflibercept and immune globulins will be subject to step therapy review in addition to medical necessity review. Step therapy will not apply to members already receiving these medications.
Action Required
By April 15, 2026: Billing team must update prior authorization workflows to require precertification for all claims using HCPCS codes C9399, J3590, J3490, and J9999 when billed for the 11 specialty drugs listed (Aukelso, Bildyos, Bilprevda, Bosaya, Enoby, Eydenzelt, Forzinity, Gammagard Liquid ERC, Inlexzo, Keytruda Qlex, Qivigy, and Xtrenbo). Configure billing system to initiate step therapy review (per Clinical Criteria Guidelines CC-0027, CC-0072, CC-0003) upon precertification initiation for denosumab biosimilars, aflibercept, and immune globulin products, but ensure step therapy is waived for members already actively receiving these medications. Update provider order entry templates and prior authorization request forms to reference the applicable Clinical Criteria Guidelines. Train clinical staff and providers on new requirements. Failure to obtain required precertification for dates of service on or after May 1, 2026 will result in claim denials. Verify member active treatment status before applying step therapy requirements.