Medicare AdvantagePrior AuthHigh impact
[California] Clinical Criteria updates
Anthem BCBS·CA · Oncology, Hematology, Rheumatology +10 more·Provider Bulletin
Effective date
Sep 28, 2026
We identified it
Aug 28, 2026
Summary
Anthem Blue Cross Medicare Advantage has revised clinical criteria for 46 specialized medications across multiple therapeutic categories (oncology, immunology, rare diseases, cardiovascular, and others), effective September 28, 2026. The policy updates medical necessity requirements for these drugs covered under the medical benefit. One new criterion was added (Avlayah). Billing teams must review updated clinical criteria documents to understand new/modified medical necessity requirements that may affect claim adjudication and prior authorization processes.
Action Required
By September 28, 2026: (1) Billing team and clinical staff must access and review all 46 revised clinical criteria documents on Anthem's Clinical Criteria page (link provided in policy). (2) Update internal prior authorization workflows and templates to reflect new/revised medical necessity requirements for each drug listed. (3) Alert providers and clinical staff that clinical coding edits for these medications will change; obtain current criteria documentation before submitting claims or prior auth requests. (4) Contact Anthem via email (address provided in policy) for clarification on specific authorization requirement changes, as this notice does not include detailed authorization details. (5) Communicate changes to all practice staff as instructed. Failure to align with new criteria may result in claim denials or delayed authorizations for affected medications.