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[California] Clinical Criteria updates

Anthem BCBS·CA · Oncology, Ophthalmology, Dermatology +6 more·Provider Bulletin
Effective date
Oct 1, 2026
We identified it
Aug 27, 2026
Days to comply
16 days

Summary

Anthem Blue Cross Medicare Advantage has revised clinical criteria for 23 specialty pharmaceutical drugs and biologics effective October 1, 2026, and added 4 new clinical criteria for recently approved medications. These updates affect medical necessity requirements and clinical coding edits for high-cost injectable and infused drugs across multiple therapeutic areas including oncology, immunology, ophthalmology, and rare disease treatments. Billing teams must obtain the detailed clinical criteria documents to understand specific documentation and authorization requirements for each affected drug.

Action Required

Before Oct 1, 2026
By September 15, 2026: Billing team and clinical staff must access Anthem's Clinical Criteria page (https://providernews.anthem.com/california/articles/clinical-criteria-updates-31686) to download and review the complete clinical criteria documents for all 27 affected drugs (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). Identify which drugs your practice administers or prescribes. Before October 1, 2026: Update clinical documentation templates, prior authorization request forms, and billing system notes to reflect any new or revised medical necessity requirements for affected medications. Train providers and clinical staff on new documentation requirements for Dupixent, Krystexxa, Palynziq, oncology checkpoint inhibitors (Yervoy, Opdivo, Tecentriq, Imfinzi, Gazyva), CAR-T therapies (Yescarta), and new drugs (Hepcludex, Decnupaz, Lumvoa, Trutakna). Notify providers that authorization rules will be communicated separately and coordinate with Anthem to obtain those details. Failure to align with revised clinical criteria will result in claim denials for medical drug benefits covered under members' medical plans.