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[Ohio] Clinical Criteria updates
Act
by Nov 28, 2026
Effective date
Nov 28, 2026
Identified
Aug 28, 2026
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.
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What to do
by Nov 28, 2026 · 4 steps
01Billing 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.
02Before November 28, 2026: Contact Anthem directly for authorization requirement details via their email contact method.
03Update provider encounter templates and billing system documentation requirements to reflect new/revised medical necessity criteria.
04Communicate changes to all clinical staff prescribing these medications.
If missed: Failure to comply with updated medical necessity criteria will result in claim denials for non-compliant submissions.
Original notice
[Ohio] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Ohio] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider Bulletin[Ohio] Clinical Criteria updatesHighEffective Jan 29, 2027 · Provider Bulletin[New York] Clinical Criteria updatesMediumEffective Nov 9, 2026 · Provider Bulletin[Ohio] Medical Policies and Clinical Utilization Management Guidelines updateHighEffective Jan 1, 2027 · Prior AuthorizationBrowse every Anthem BCBS change in the policy list