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Anthem BCBSMedicare Advantage · Prior Auth · Provider Bulletin · VA · Oncology, Hematology, Rheumatology +9 moreHigh impact

[Virginia] Clinical Criteria updates

Act
by Nov 29, 2026
Effective date
Nov 29, 2026
Identified
Oct 24, 2026

Summary

Anthem Blue Cross and Blue Shield has revised 60 clinical criteria policies for medical drug benefits effective November 29, 2026. These revisions affect medical necessity requirements for specialty pharmaceuticals across multiple therapeutic categories including oncology agents, biologics, growth hormones, and rare disease treatments. Billing and clinical teams must review updated criteria in the Clinical Criteria page and coordinate with authorization requirements communicated separately.

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What to do

by Nov 29, 2026 · 6 steps
01Billing team and clinical staff should.
02Access Anthem's Clinical Criteria page to review the 60 revised policies (CC-0001 through CC-0310 series) to understand updated medical necessity requirements.
03Verify current authorization processes for affected specialty drugs, as authorization rules are communicated separately and may differ from clinical criteria changes.
04Confirm applicability to your Medicare Advantage members in Virginia and other Anthem-served states.
05Alert prescribers and prior authorization staff of potential workflow impacts for the listed drug categories (erythropoiesis stimulating agents, monoclonal antibodies, TNF antagonists, oncology immunotherapies, rare disease agents, and others).
06Test billing system logic to ensure claims processing aligns with new medical necessity edits effective November 29, 2026.
If missed: Failure to implement revised criteria may result in claim denials or delays for non-compliant authorizations.

Original notice

[Virginia] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
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Related changes

See all Anthem BCBS changes →
[New York] Clinical Criteria updates (November 2026 Newsletter)MediumNo effective date · Provider Bulletin[Virginia] Clinical Criteria updates (November 2026 Newsletter)LowNo effective date · Provider Bulletin[California] Clinical Criteria updates (November 2026 Newsletter)MediumNo effective date · Provider Bulletin[California] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list

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