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[Virginia] Clinical Criteria updates
Act
by Nov 20, 2026
Effective date
Nov 20, 2026
Identified
Oct 16, 2026
Summary
HealthKeepers, Inc. (Anthem HealthKeepers Plus Medicaid) is revising 24 clinical criteria for medical drug benefits, affecting coverage requirements for oncology drugs, immunology agents, ophthalmology implants, and specialty pharmaceuticals. Twenty-two existing criteria are being revised (including Opdivo, Yervoy, Tecentriq, and others) and four new criteria are being added (Hepcludex, Decnupaz, Lumvoa, Trutakna). All changes take effect November 20, 2026.
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What to do
by Nov 20, 2026 · 3 steps
01Billing team must obtain and review the revised clinical criteria for all 26 affected drugs (24 revisions + 4 new criteria) from HealthKeepers' Clinical Criteria page to understand updated medical necessity requirements for medical drug benefit coverage.
02Update internal authorization and coverage templates to reflect revised criteria for: Ocrevus (CC-0011), Dupixent (CC-0029), Intravitreal Corticosteroid Implants (CC-0031), Botulinum Toxin (CC-0032), Monoclonal Antibodies to Interleukin-5 (CC-0043), Krystexxa (CC-0057), Palynziq (CC-0077), Abraxane (CC-0099), Xofigo (CC-0112), Yervoy (CC-0119), Gazyva (CC-0121), Opdivo (CC-0125), Tecentriq/Atezolizumab (CC-0128), Imfinzi (CC-0130), Yescarta (CC-0151), Enhertu (CC-0158), Durysta (CC-0163), Xipere (CC-0218), Qalsody (CC-0237), Vyjuvek (CC-0243), iDose TR (CC-0258), Tryngolza (CC-0276), Datroway (CC-0279), and Opdivo Qvantig (CC-0281), plus implement new criteria for Hepcludex (CC-0303), Decnupaz (CC-0304), Lumvoa (CC-0305), and Trutakna (CC-0306).
03Note: Clinical criteria apply only to medical drug benefits, not pharmacy services; separate authorization rules will be communicated separately.
If missed: Failure to implement updated criteria may result in claim denials or processing delays for affected medications.
Original notice
[Virginia] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[Virginia] Clinical Criteria updatesHighEffective Nov 29, 2026 · Provider Bulletin[Virginia] Clinical Criteria updatesHighEffective Sep 28, 2026 · Provider Bulletin[Virginia] Clinical Criteria updatesHighEffective Oct 1, 2026 · Provider Bulletin[Virginia] Clinical Criteria updatesHighEffective Aug 1, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list