Medicare AdvantageCoverageHigh impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Oncology, Hematology, Neurology +7 more·Provider Bulletin
Effective date
Sep 23, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross Blue Shield has revised 27 clinical criteria policies for medical drug benefits effective September 23, 2026, affecting high-cost specialty medications including immunoglobulins, oncology agents (Keytruda, Tecentriq, Atezolizumab), multiple sclerosis treatments, hemophilia agents, and rare disease therapies. Two new criteria have also been added. These revisions may impact medical necessity requirements and prior authorization processes for these drug categories.
Action Required
By September 23, 2026: Billing and clinical teams must access Anthem's Clinical Criteria page and review all 27 revised criteria (CC-0003, CC-0011, CC-0027, CC-0029, CC-0058, CC-0065, CC-0068, CC-0072, CC-0104, CC-0124, CC-0127, CC-0128, CC-0142, CC-0149, CC-0159, CC-0174, CC-0182, CC-0213, CC-0222, CC-0227, CC-0229, CC-0235, CC-0236, CC-0263) and two new criteria (CC-0300 Yuviwel, CC-0301 Loargys) to identify specific changes to medical necessity documentation requirements. Update EMR templates, prior authorization submission protocols, and clinical documentation guidelines to reflect revised criteria. Distribute updated clinical criteria documentation to prescribing providers. Note: These criteria apply ONLY to medical drug benefits, not pharmacy services. Separate authorization requirement notices will be provided by Anthem. Failure to comply with updated criteria may result in claim denials for medical drug benefit coverage.