MedicaidPrior AuthHigh impact
[California] Clinical Criteria updates
Anthem BCBS·CA · Allergy & Immunology, Hematology, Oncology +8 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 25, 2026
Summary
Anthem Blue Cross Medi-Cal has revised clinical criteria for 47 medications across immunology, oncology, hematology, and rare disease categories, effective October 1, 2026. These revisions update medical necessity requirements for drugs administered as medical benefits (not pharmacy). Billing teams must obtain updated clinical criteria documents to understand new authorization rules and documentation requirements for affected drug codes.
Action Required
By September 15, 2026: Billing and clinical teams must obtain the full clinical criteria documents for all 50 revised/new policies (CC-0002 through CC-0299) from Anthem's Clinical Criteria page. For each affected drug, verify: (1) current medical necessity requirements have changed, (2) new documentation must be collected from providers, (3) prior authorization workflows need updating in billing system. Contact Anthem via the provided email address to clarify which criteria changes affect your patient population. Identify which of these 50 drugs your practice prescribes/administers and update encounter forms, EMR templates, and prior auth protocols accordingly. Failure to implement updated clinical criteria will result in claim denials for medical drug benefits effective October 1, 2026.