Medicare AdvantageCoverageHigh impact
[California] Clinical Criteria updates
Anthem BCBS·CA · Oncology, Hematology, Endocrinology +4 more·Provider Bulletin
Effective date
Jul 12, 2026
We identified it
Jun 13, 2026
Summary
Anthem Medicare Advantage has revised clinical criteria for 24 specialty medications including cancer drugs, growth hormones, and immunoglobulins, and added 2 new drug criteria. These changes may affect prior authorization requirements and coverage decisions for high-cost specialty medications administered in medical settings.
Action Required
By July 12, 2026: Review updated clinical criteria for all 26 listed specialty medications on Anthem's Clinical Criteria page. Billing team must verify current authorization requirements for affected drugs including Keytruda, Dupixent, Ocrevus, growth hormones, and immunoglobulins before administration. Update prior authorization workflows and staff training for new criteria requirements.