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[California] Clinical Criteria updates

Anthem BCBS·CA · Allergy & Immunology, Dermatology, Endocrinology +7 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Jun 26, 2026
Days to comply
97 days

Summary

Anthem Blue Cross Medi-Cal has revised 29 clinical criteria policies and added 2 new ones, effective October 1, 2026. These changes apply to medical drug benefits for specialty medications including immunoglobulins, monoclonal antibodies, growth hormones, cancer therapies, and rare disease treatments. Billing teams must review updated clinical criteria documentation to understand new or modified medical necessity requirements for prior authorization and claim processing.

Action Required

Before Oct 1, 2026
By September 15, 2026: Billing team and clinical staff must access Anthem's Clinical Criteria page to review the full text of all 31 updated policies (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). Identify specific changes to medical necessity requirements, documentation needs, and authorization triggers for each drug. Update billing software, prior authorization workflows, and provider education materials to reflect revised criteria. Train providers and coders on new requirements for the two newly published criteria (CC-0300 Yuviwel and CC-0301 Loargys). Notify all clinical and billing staff that authorization rules are communicated separately and will be distributed via additional notice. Failure to comply with updated clinical criteria may result in claim denials for medical drug benefits under Medi-Cal Managed Care plans.