Medicare AdvantageDocumentationHigh impact
[Georgia] Clinical Criteria updates
Anthem BCBS·GA · Oncology, Allergy & Immunology, Dermatology +9 more·Provider Bulletin
Effective date
Sep 28, 2026
We identified it
Aug 28, 2026
Summary
Anthem Blue Cross Blue Shield (Georgia) has revised 40 clinical criteria policies for specialty medications effective September 28, 2026. These revisions update medical necessity requirements for high-cost drugs across oncology, immunology, rare disease, and specialty care. Billing teams must review updated clinical criteria documentation to ensure claims meet new medical necessity standards for medical drug benefits (not pharmacy).
Action Required
By September 28, 2026: (1) Billing team and clinical staff must access and review all 40 revised clinical criteria policies on Anthem's Clinical Criteria page (https://providernews.anthem.com/georgia/articles/clinical-criteria-updates-31716). (2) For each affected specialty medication (e.g., Keytruda, Opdivo, Bevacizumab, Dupixent, Xolair), confirm current medical necessity documentation requirements in patient charts and claims submission processes. (3) Update internal billing protocols and EMR templates to reflect any new or removed medical necessity requirements for medical drug benefits administered through medical plans (not pharmacy). (4) Communicate policy changes to all clinical providers and front-desk staff. (5) Monitor for separate authorization rules notice from Anthem, which will detail specific prior authorization workflows. Failure to comply with updated clinical criteria will result in claim denials for medical drug benefit services.