MedicaidPrior AuthHigh impact
[Ohio] Clinical Criteria updates
Anthem BCBS·OH · Oncology, Hematology, Radiation Oncology·Provider Bulletin
Effective date
Jan 1, 2027
We identified it
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.
Action Required
By December 15, 2026: Billing 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. Update billing system rules and prior authorization workflows for all six affected drug products. Providers 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. Distribute revised clinical criteria and prior authorization requirements to all clinical staff and providers. Failure to comply with updated medical necessity criteria will result in claim denials for Ohio Medicaid/MyCare Ohio members.