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[Ohio] Clinical Criteria updates
Act
by Jan 29, 2027
Effective date
Jan 29, 2027
Identified
Oct 25, 2026
Summary
Anthem Blue Cross and Blue Shield is revising 50 clinical criteria policies for medical drug benefits covering specialty medications across oncology, immunology, rare diseases, and metabolic conditions. These revised criteria will establish updated medical necessity requirements effective January 29, 2027, and apply only to medical drug benefits (not pharmacy services). Billing teams must review updated clinical criteria documentation for affected medications to ensure compliance with new authorization and coverage requirements.
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What to do
by Jan 29, 2027 · 5 steps
01Billing and clinical staff must obtain and review the revised Clinical Criteria policies (CC-0001 through CC-0310, specifically all 50 revised criteria listed) from Anthem's Clinical Criteria page.
02Update prior authorization workflows and billing system edits to reflect any changes to medical necessity requirements for the affected medications, including: Erythropoiesis Stimulating Agents, Colony Stimulating Factor Agents, Subcutaneous Hormonal Implants, Testosterone Injectable, Denosumab, Benlysta, Hereditary Angioedema Agents, specialty oncology drugs (Keytruda, Darzalex, Provenge, Sarclisa, Trodelvy, and 35+ others), and rare disease/metabolic agents.
03Verify authorization rules through separate Anthem notices, as this bulletin covers clinical criteria only, not authorization requirements.
04Confirm applicability to specific member plans, as these criteria apply only to medical drug benefits included in the member's medical plan.
05Contact Anthem via the provided email for specific policy details and implementation questions.
Original notice
[Ohio] Clinical Criteria updates
providernews.anthem.com · Always check the source before changing claims.
Related changes
See all Anthem BCBS changes →[California] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider Bulletin[New York] Clinical Criteria updatesHighEffective Nov 29, 2026 · Provider Bulletin[Ohio] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider Bulletin[Georgia] Clinical Criteria updatesMediumEffective Nov 29, 2026 · Provider BulletinBrowse every Anthem BCBS change in the policy list