Medicare AdvantageCoverageMedium impact
[Georgia] Clinical Criteria updates
Anthem BCBS·GA · Oncology, Hematology, Rheumatology +5 more·Provider Bulletin
Effective date
Apr 4, 2026
We identified it
May 18, 2026
Summary
Anthem has updated clinical criteria for 23 medications and biologics used in medical drug benefits, effective April 4, 2026. Of these, 20 are revisions to existing criteria (CC-0002 through CC-0276) and 3 are newly published criteria (CC-0294, CC-0295, CC-0296). The billing team must verify whether any of these revised or new criteria affect prior authorization requirements, medical necessity documentation, or coverage determinations for claims submitted under Anthem Medicare Advantage plans in Georgia.
Action Required
By April 4, 2026: Billing and prior authorization teams must obtain the full text of all 23 revised and new Clinical Criteria policies from Anthem's Clinical Criteria page (referenced in the bulletin). For each policy, determine if medical necessity requirements, prior authorization rules, or coverage conditions have changed. Update internal billing guidelines, EMR templates, and prior authorization workflows accordingly. Contact Anthem at the provided email address if authorization requirements are unclear. Clinical Criteria apply ONLY to medical drug benefits under medical plans, not pharmacy benefits—ensure billing staff routes claims to the correct department. Failure to apply updated criteria may result in claim denials or incorrect authorization determinations.