MedicaidPrior AuthHigh impact
[New York] Clinical Criteria updates
Anthem BCBS·NY · Oncology, Rheumatology, Hematology +9 more·Provider Bulletin
Effective date
Mar 22, 2026
We identified it
May 3, 2026
Summary
Anthem has updated clinical criteria for 47 medical drug benefit policies effective March 22, 2026, including 2 newly published criteria (Forzinity and Inlexzo) and 45 revised criteria affecting immunologic, oncologic, hematologic, and other specialty drugs. These changes apply to medical plan drug benefits only (not pharmacy services) and may affect prior authorization requirements, medical necessity documentation, and billing for affected drug therapies.
Action Required
By March 22, 2026: (1) Billing team must review the full clinical criteria policy documents for each affected drug via Anthem's Clinical Criteria page to identify any new medical necessity requirements or prior authorization changes. (2) Update billing system rules and encounter documentation templates to reflect revised medical necessity criteria for all 47 affected drugs, particularly high-volume specialty drugs (Keytruda, Tecentriq, Ocrevus, TNF antagonists, IL-6 inhibitors, VEGF inhibitors, rituximab agents). (3) Clinical staff and providers must ensure all claims for affected drugs include documentation supporting medical necessity per updated criteria; claims lacking required documentation will be denied. (4) Contact Anthem directly via the email address listed in the bulletin for clarification on specific authorization requirements, which are communicated separately from clinical criteria. (5) Distribute this notice to all clinical and billing staff involved in prior authorization and specialty drug billing.