High impact
[New York] Clinical Criteria updates
Anthem BCBS·Effective Aug 1, 2026
Anthem has revised clinical criteria for 25 specialty pharmaceutical agents and injectable drugs effective August 1, 2026, and added 2 new criteria. These revisions affect medical necessity requirements and clinical coding edits for high-cost specialty medications across multiple therapeutic categories (immunology, oncology, hematology, endocrinology, and rare diseases). Billing teams must obtain and review the updated clinical criteria documents to ensure claims compliance, as authorization requirements are communicated separately.