MedicaidDocumentationMedium impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Oncology, Hematology, Rheumatology +2 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Ohio Medicaid has revised clinical criteria for 9 specialty pharmaceutical drugs effective October 1, 2026. These revisions may affect medical necessity requirements and billing for these drugs when billed under the medical benefit (not pharmacy benefit). The billing team must obtain and review the detailed revised clinical criteria documents to understand specific documentation and authorization changes required.
Action Required
By September 15, 2026: Billing team must access Anthem's Clinical Criteria page and download the revised criteria for all 9 drugs listed (CC-0266, CC-0268, CC-0281, CC-0247, CC-0257, CC-0254, CC-0246, CC-0202, CC-0262). Review each document to identify specific changes to medical necessity requirements. Update prior authorization workflows and encounter documentation templates accordingly. Notify all providers and clinical staff of changes. Contact Anthem via the provided email for clarification on specific authorization requirements before the October 1, 2026 effective date. Claims submitted without compliance with revised criteria may be denied. Note: This applies ONLY to medical drug benefits, not pharmacy services.