MedicaidPrior AuthHigh impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Oncology, Rheumatology, Neurology +4 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross and Blue Shield Ohio Medicaid updated clinical criteria for 26 specialized medications effective October 1, 2026. Twenty-three existing criteria were revised (modifying medical necessity requirements), and three new criteria were added for recently approved biologics. These changes apply to medical drug benefits only and may affect prior authorization requirements, which will be communicated separately.
Action Required
By September 1, 2026: Billing and clinical teams must obtain the full revised Clinical Criteria documents from Anthem's Clinical Criteria page for all 26 affected medications (CC-0003, CC-0020, CC-0028, CC-0041, CC-0072, CC-0075, CC-0079, CC-0110, CC-0121, CC-0124, CC-0127, CC-0128, CC-0130, CC-0157, CC-0166, CC-0167, CC-0187, CC-0193, CC-0209, CC-0227, CC-0242, CC-0276, CC-0294, CC-0295, CC-0296). Review each for changes to medical necessity requirements and document submission standards. Identify which medications are commonly prescribed in your practice. Coordinate with providers and prior authorization teams to understand new/revised requirements. Update internal guidelines, encounter forms, and billing software authorization rules as needed. Watch for separate authorization requirements notice from Anthem. Failure to comply with revised clinical criteria may result in claim denials for Ohio Medicaid members. Contact Anthem via the provided email for clarification on specific criteria changes.