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[New York] Clinical Criteria updates

Anthem BCBS·NY · Oncology, Dermatology, Ophthalmology +7 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 27, 2026
Days to comply
16 days

Summary

Anthem Blue Cross and Blue Shield has revised 22 clinical criteria policies and added 4 new ones for medical drug benefits, effective October 1, 2026. These updates affect high-cost specialty medications including immunotherapies, biologics, and advanced therapeutics. The policy document does not specify detailed clinical requirement changes but directs providers to the Clinical Criteria page for specific authorization rules that will be communicated separately.

Action Required

Before Oct 1, 2026
By September 15, 2026: Billing team must identify all affected specialty medications (Dupixent, Opdivo, Yervoy, Tecentriq, Imfinzi, Yescarta, Enhertu, Qalsody, Vyjuvek, Hepcludex, Decnupaz, Lumvoa, Trutakna, and others listed) and cross-reference current claim submission processes. Access Anthem's Clinical Criteria page to retrieve full policy details for 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, and CC-0306. Providers must review the revised medical necessity criteria and update prior authorization processes accordingly. Billing team must monitor for separate authorization requirement notices from Anthem. Update internal clinical criteria tracking spreadsheet with new effective dates. Establish escalation process for claims submitted 9/15-9/30 that may be affected by the transition. Failure to align with revised criteria may result in claim denials or delays for medical drug benefit claims.