← Back to list
[Ohio] Clinical Criteria updates
Act
by Nov 15, 2026
Effective date
Dec 1, 2026
Identified
Aug 27, 2026
Summary
Anthem Blue Cross and Blue Shield has revised 23 clinical criteria policies and added 4 new ones for medical drug benefits under Medicare Advantage/MyCare Ohio plans, effective December 1, 2026. These updates affect prior authorization and medical necessity requirements for specialty medications across oncology, immunology, ophthalmology, and rare disease categories. Billing teams must obtain updated clinical criteria documentation to ensure accurate prior authorization submissions and claim processing.
Get alerts when payers change rules like this one
We check Anthem BCBS and other payers every day and email you when a change matches your specialty and state.
Get Anthem BCBS alertsPolicy Monitoring is free. No card required.
What to do
by Nov 15, 2026 · 3 steps
01Billing team and providers must review the 27 updated clinical criteria policies (CC-0029, CC-0031, CC-0032, CC-0043, CC-0057, CC-0061, CC-0077, CC-0099, CC-0112, CC-0119, CC-0121, CC-0125, CC-0128, CC-0130, CC-0151, CC-0158, CC-0163, CC-0218, CC-0237, CC-0243, CC-0258, CC-0276, CC-0279, CC-0281, CC-0303, CC-0304, CC-0305, CC-0306) on Anthem's Clinical Criteria page to identify specific changes to medical necessity requirements.
02Contact Anthem immediately via the provided email to obtain detailed authorization requirements for each revised and new criterion.
03Update billing software, prior authorization templates, and clinical documentation requirements to reflect the new criteria.
If missed: Failure to comply with updated medical necessity requirements will result in claim denials for affected specialty medications, particularly for oncology immunotherapies, biologic agents, and rare disease treatments.
Original notice
[Ohio] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Ohio] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider Bulletin[Ohio] Clinical Criteria updatesHighEffective Jan 29, 2027 · Provider Bulletin[New York] Clinical Criteria updatesMediumEffective Nov 9, 2026 · Provider Bulletin[Ohio] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Jan 1, 2027 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list