Medicare AdvantageCoverageMedium impact
[California] Clinical Criteria updates
Anthem BCBS·CA · Oncology, Hematology, Endocrinology +3 more·Provider Bulletin
Effective date
Apr 4, 2026
We identified it
May 3, 2026
Summary
Anthem has updated clinical criteria for 23 medical drug benefit policies effective April 4, 2026, with 20 revised existing criteria and 3 newly published criteria. These changes affect medical necessity requirements for specialty drugs including cancer immunotherapies, monoclonal antibodies, and rare disease treatments. Billing teams must verify current clinical criteria documentation requirements for affected drug administrations to ensure claim approval.
Action Required
By April 4, 2026: Billing and clinical staff must access Anthem's Clinical Criteria page to review specific updates for all 23 affected drug policies (CC-0002, CC-0010, CC-0027, CC-0028, CC-0043, CC-0072, CC-0079, CC-0110, CC-0121, CC-0124, CC-0127, CC-0128, CC-0130, CC-0157, CC-0187, CC-0193, CC-0229, CC-0242, CC-0276, CC-0294, CC-0295, CC-0296). Obtain full policy text for each revised criterion to identify any changes to medical necessity requirements. Update internal documentation templates and provider education materials to reflect new/revised criteria. Alert prescribing providers of changes, particularly those in oncology, hematology, and rare disease specialties. Monitor claims for denials related to outdated documentation. Note: Clinical criteria changes may trigger separate prior authorization requirement updates—watch for a separate authorization notice from Anthem.