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[Ohio] Clinical Criteria updates

Anthem BCBS·OH · Oncology, Hematology, Rheumatology +9 more·Provider Bulletin
Effective date
Nov 28, 2026
We identified it
Aug 28, 2026
Days to comply
74 days

Summary

Anthem Blue Cross and Blue Shield Ohio has revised 44 clinical criteria policies for medical drug benefits covering specialty pharmaceuticals (oncology agents, immunology drugs, rare disease treatments, and biologic therapies) effective November 28, 2026. One new criterion (CC-0302 Avlayah) has been added. These revisions update medical necessity requirements and coding edits but do not specify authorization requirement changes—those will be communicated separately. This affects Medicare Advantage and MyCare Ohio members only.

Action Required

Before Nov 28, 2026
By November 28, 2026: Billing and clinical staff must review the revised clinical criteria for all 45 affected drugs (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 Anthem's Clinical Criteria page and document any changes to medical necessity requirements. Before November 28, 2026: Contact Anthem directly for authorization requirement details via their email contact method. Update provider encounter templates and billing system documentation requirements to reflect new/revised medical necessity criteria. Communicate changes to all clinical staff prescribing these medications. Failure to comply with updated medical necessity criteria will result in claim denials for non-compliant submissions.