MedicaidDocumentationMedium impact
[Virginia] Clinical Criteria updates
Anthem BCBS·VA · Oncology, Hematology, Rheumatology +8 more·Provider Bulletin
Effective date
Mar 22, 2026
We identified it
May 3, 2026
Summary
HealthKeepers, Inc. (Virginia Medicaid) updated clinical criteria for 47 drug policies effective March 22, 2026, including 2 new criteria (Forzinity and Inlexzo) and 45 revised criteria affecting immunologic, oncologic, hematologic, and specialty pharmaceutical benefits. These updates support clinical coding edits for medical drug benefits and may affect prior authorization and medical necessity documentation requirements.
Action Required
By March 22, 2026: Billing team must obtain and review the detailed clinical criteria documents for all 47 updated policies from HealthKeepers' Clinical Criteria page (https://providernews.anthem.com/virginia/articles/clinical-criteria-updates-28818). For each revised criteria, identify changes to medical necessity requirements and update billing workflows, EMR templates, and prior authorization submission processes accordingly. Communicate specific changes to providers and clinical staff who prescribe affected drugs (including immunosuppressants, monoclonal antibodies, oncologic agents, hematologic agents, and specialty injectables). Update internal documentation requirements to reflect new/revised medical necessity standards. Note: Authorization rules are communicated separately—monitor for companion notices. Failure to comply with updated clinical criteria may result in claim denials for medical drug benefits under Virginia Medicaid plans.