Back to dashboard
Medicare AdvantageCoverageHigh impact

[Virginia] Clinical Criteria updates

Anthem BCBS·VA · Oncology, Hematology, Cardiology +9 more·Provider Bulletin
Effective date
Sep 28, 2026
We identified it
Aug 28, 2026
Days to comply
13 days

Summary

Anthem Blue Cross and Blue Shield (Virginia) has revised 44 clinical criteria policies for medical drug benefits, effective September 28, 2026. These revisions update medical necessity requirements for specialty and oncologic medications administered as medical benefits (not pharmacy). Billing teams must obtain and reference updated clinical criteria documentation to ensure claims align with new authorization and coverage requirements.

Action Required

Before Sep 28, 2026
By September 28, 2026: (1) Billing team must access and review all 44 revised Clinical Criteria policies (CC-0002, CC-0010, CC-0024, CC-0027, CC-0029, CC-0033, CC-0042, CC-0048, CC-0051, CC-0063, CC-0072, CC-0087, CC-0092, CC-0094, CC-0101, CC-0102, CC-0105, CC-0106, CC-0107, CC-0108, CC-0111, CC-0114, CC-0116, CC-0124, CC-0130, CC-0143, CC-0145, CC-0153, CC-0158, CC-0160, CC-0162, CC-0165, CC-0169, CC-0175, CC-0188, CC-0201, CC-0206, CC-0207, CC-0209, CC-0225, CC-0240, CC-0252, CC-0262, CC-0264, CC-0274, CC-0276, CC-0281, CC-0284, CC-0285, CC-0294, CC-0299, CC-0302) on the Anthem Clinical Criteria page. (2) Providers and clinical staff must update medical necessity documentation templates and pre-authorization protocols to reflect new or removed requirements. (3) Billing team must verify prior authorization rules via separate Anthem authorization notice (not included in this bulletin). (4) Update internal reference materials and staff training for affected drug products listed. Failure to align claims with revised criteria may result in denials. Note: These criteria apply ONLY to medical drug benefits, not pharmacy services.