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[Virginia] Clinical Criteria updates

Anthem BCBS·VA · Hematology, Oncology, Neurology +6 more·Provider Bulletin
Effective date
Jul 23, 2026
We identified it
Jun 25, 2026
Days to comply
27 days

Summary

Anthem has revised clinical criteria for 25 specialty pharmaceutical drugs and biologics effective July 23, 2026, plus introduced 2 new criteria. These are medical drug benefit policies (not pharmacy) that may affect prior authorization and medical necessity requirements for high-cost injectable and infused medications. The practice must review each specific criterion to identify changes to requirements and update authorization workflows accordingly.

Action Required

Before Jul 23, 2026
By July 23, 2026: (1) Billing and prior authorization team must access Anthem's Clinical Criteria portal (https://providernews.anthem.com/virginia/articles/clinical-criteria-updates-30731) and download the full revised criteria for all 27 items listed (CC-0003 through CC-0301). (2) For each revised criterion, identify specific changes to medical necessity requirements, documentation needed, and any new authorization triggers. (3) Update all EMR templates, prior authorization submission protocols, and billing system edits to reflect new requirements for affected drug categories: immunoglobulins, Ocrevus, Denosumab, Dupixent, Octreotide agents, Hemophilia/vWD agents, Growth Hormone, VEGF inhibitors, Levoleucovorin/Leucovorin, Keytruda, Darzalex, Atezolizumab, Somatuline, clotting agents, Scenesse, Kesimpta, Iron agents, Voxzogo, Tecvayli, Briumvi, Sunlenca, Revcovi, Pasireotide, Imdelltra, Yuviwel, and Loargys. (4) Notify all providers and clinical staff of changes. (5) Claims submitted without updated documentation or authorization per new criteria will be denied. Contact Anthem via the provider bulletin email for clarification on specific requirement changes before implementation.