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[New York] Clinical Criteria updates

Anthem BCBS·NY · Allergy & Immunology, Oncology, Hematology +6 more·Provider Bulletin
Effective date
Aug 1, 2026
We identified it
Jun 26, 2026
Days to comply
36 days

Summary

Anthem has revised clinical criteria for 25 specialty pharmaceutical agents and injectable drugs effective August 1, 2026, and added 2 new criteria. These revisions affect medical necessity requirements and clinical coding edits for high-cost specialty medications across multiple therapeutic categories (immunology, oncology, hematology, endocrinology, and rare diseases). Billing teams must obtain and review the updated clinical criteria documents to ensure claims compliance, as authorization requirements are communicated separately.

Action Required

Before Aug 1, 2026
By July 31, 2026: (1) Billing team and clinical staff must access and review all 27 updated clinical criteria documents (CC-0002, CC-0003, CC-0011, CC-0029, CC-0034, CC-0043, CC-0058, CC-0065, CC-0068, CC-0072, CC-0104, CC-0107, CC-0124, CC-0127, CC-0128, CC-0142, CC-0149, CC-0159, CC-0166, CC-0174, CC-0182, CC-0213, CC-0222, CC-0227, CC-0229, CC-0235, CC-0236, CC-0263, CC-0300, CC-0301) on Anthem's Clinical Criteria page to identify specific medical necessity requirement changes. (2) Update billing software, EMR templates, and prior authorization workflows to reflect revised criteria for each drug/agent. (3) Alert prescribing providers of changes to clinical coding edits and documentation requirements for affected specialty medications. (4) Identify any new authorization requirements via separate Anthem notice and incorporate into claim submission protocols. Failure to apply updated criteria may result in claim denials for medical drug benefits on Anthem Medicaid plans in New York.