Medicare AdvantageDocumentationHigh impact
[New York] Clinical Criteria updates
Anthem BCBS·NY · Oncology, Allergy & Immunology, Hematology +7 more·Provider Bulletin
Effective date
Sep 28, 2026
We identified it
Aug 28, 2026
Summary
Anthem Blue Cross and Blue Shield has revised 46 clinical criteria policies for medical drug benefits under Medicare Advantage plans in New York, effective September 28, 2026. These revisions update medical necessity requirements for specialty pharmaceuticals across multiple therapeutic categories including oncology agents, immunology drugs, and rare disease treatments. Billing teams must obtain updated clinical criteria documentation and ensure claims comply with revised medical necessity standards.
Action Required
By September 28, 2026: (1) Billing team must access and review each of the 46 revised clinical criteria documents listed in the policy via Anthem's Clinical Criteria page (reference Clinical Criteria numbers CC-0002 through CC-0302). (2) For each drug affected (colony stimulating factors, PCSK9 inhibitors, Dupixent, Keytruda, Opdivo, Imfinzi, immunology agents, oncology therapeutics, and rare disease treatments), update internal documentation templates and EMR prior authorization triggers to reflect new or modified medical necessity requirements. (3) Provider teams must document medical necessity according to revised criteria before submitting claims for these specialty drugs on medical benefits. (4) Contact Anthem via the provided email for specific authorization requirements, as this notice does not detail authorization workflow changes. (5) Share this notice with all clinical staff and providers. Failure to comply with revised clinical criteria will result in claim denials for medical drug benefits under Medicare Advantage plans. Note: These criteria apply ONLY to medical drug benefits, not pharmacy services.