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[Ohio] Clinical Criteria updates
Act
by Dec 15, 2026
Effective date
Jan 1, 2027
Identified
Aug 27, 2026
Summary
Anthem Ohio Medicaid/MyCare Ohio has revised six clinical criteria policies for medical drug benefits, effective January 1, 2027. These revisions affect asparagine-specific enzymes, bevacizumab, radioimmunotherapy agents, nivolumab, avelumab, and amivantamab products. Billing teams must review updated medical necessity requirements and obtain prior authorization according to separate notice guidance to avoid claim denials.
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What to do
by Dec 15, 2026 · 4 steps
01Billing and clinical teams must obtain and review the complete revised clinical criteria policies (CC-0096, CC-0107, CC-0118, CC-0125, CC-0129, CC-0201) from Anthem's Clinical Criteria page.
02Update billing system rules and prior authorization workflows for all six affected drug products.
03Providers must document updated medical necessity requirements on all claims for asparagine-specific enzymes, bevacizumab (and biosimilars), radioimmunotherapy agents (Azedra, Lutathera, Pluvicto, Zevalin), Opdivo (nivolumab), Bavencio (avelumab), and Rybrevant products effective January 1, 2027.
04Distribute revised clinical criteria and prior authorization requirements to all clinical staff and providers.
If missed: Failure to comply with updated medical necessity criteria will result in claim denials for Ohio Medicaid/MyCare Ohio members.
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[Ohio] Clinical Criteria updatesMediumEffective Nov 28, 2026 · Provider Bulletin[Ohio] Clinical Criteria updatesHighEffective Dec 1, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list