MedicaidPrior AuthHigh impact
[New York] Clinical Criteria updates
Anthem BCBS·NY · Oncology, Rheumatology, Allergy & Immunology +5 more·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem has revised clinical criteria for 47 specialty medications and biologics on New York Medicaid medical drug benefits, effective August 1, 2026. These revisions update medical necessity requirements and clinical coding edits for immunologic, oncologic, and specialty infusion therapies. Billing teams must obtain and review the updated clinical criteria documents to ensure claims meet new requirements.
Action Required
By July 31, 2026: Billing team and clinical staff must access Anthem's Clinical Criteria page (referenced in bulletin) and download the specific policy documents for all 47 revised and 3 newly published criteria listed in this bulletin. For each affected drug/biologic used by your practice: (1) Identify which clinical criteria apply to your patient population; (2) Review changes to medical necessity requirements; (3) Update prior authorization submission templates and documentation checklists in your billing system to reflect new requirements; (4) Train providers and front-desk staff on any new documentation or authorization workflows for affected medications. Communicate revised criteria to your clinical staff. Failure to comply with updated clinical criteria will result in claim denials for non-compliant submissions on or after August 1, 2026. This affects all New York Medicaid medical drug benefit claims for the 50 affected medications including Colony Stimulating Factors, monoclonal antibodies (IL-17, IL-5, IL-23, IL-6), TNF antagonists, oncology agents (Keytruda, Opdivo, Tecentriq, Bavencio, and others), and rare disease therapies.