Anthem Coverage Criteria
Latest Anthem coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Atezolizumab (Tecentriq, Tecentriq Hybreza) coverage criteriaClinical prior authorization and coverage criteria for Tecentriq (atezolizumab) and Tecentriq Hybreza across multiple oncology indications, specifying clinical scenarios, combinations, and restrictions for Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Four Tier Drug Plan (Formulary) — Coverage CriteriaThis document governs the prescription drug list (formulary) for Anthem members, describing covered drugs, tier placement, restrictions (e.g., prior authorization, step therapy, quantity limits), and member resources; it affects members and providers using Anthem pharmacy benefits.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Home Sleep Studies — Coverage CriteriaPolicy governs coverage of medically necessary home sleep studies for Anthem Blue Cross and Blue Shield HP Medicaid members and outlines eligibility and enrollment information for adults assessed by their provider.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Home Sleep Study (居家睡眠研究) Coverage CriteriaThis document governs coverage of medically necessary home sleep studies for Anthem Blue Cross and Blue Shield HP Medicaid members aged 18 and older, effective April 1, 2026. It explains eligibility and that home sleep testing is a voluntary alternative to in-lab sleep studies but not always clinically appropriate.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Aristada Initio (aripiprazole lauroxil) — Medical Necessity and Prior Authorization CriteriaMedical necessity criteria and coding for Aristada Initio (aripiprazole lauroxil) long-acting injectable for initiation or re-initiation of Aristada therapy in adults with schizophrenia; applies to medical benefit prior authorization determinations.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Asparagine Specific Enzymes (Erwinaze, Rylaze, Oncaspar, Asparlas)Clinical coverage criteria and coding for asparagine-specific enzyme therapies (Erwinaze, Rylaze, Oncaspar, Asparlas) primarily for acute lymphoblastic leukemia (ALL) and select lymphomas; governs prior authorization/medical necessity determinations for Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Asparagine Specific Enzymes (Erwinaze, Rylaze, Oncaspar, Asparlas) Coverage CriteriaClinical coverage criteria for asparagine specific enzymes (Erwinaze, Rylaze, Oncaspar, Asparlas) for treatment of acute lymphoblastic leukemia and select NK/T-cell lymphomas; applies to Anthem medical benefit reviews and prior authorization for covered members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Atezolizumab (Tecentriq, Tecentriq Hybreza) Coverage CriteriaClinical medical policy governing medical-benefit coverage and prior authorization criteria for atezolizumab products (Tecentriq and Tecentriq Hybreza) for oncology indications, applicable to Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Besponsa (inotuzumab ozogamicin) Medical Drug Clinical CriteriaClinical criteria governing prior authorization and medical necessity determinations for Besponsa (inotuzumab ozogamicin) use for CD22+ B-cell acute lymphoblastic leukemia (ALL), including frontline induction and relapsed/refractory settings; applies to Anthem members subject to medical benefit review.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Blincyto (blinatumomab) — Coverage CriteriaClinical criteria governing prior authorization and medical necessity for Blincyto (blinatumomab) for treatment of CD19+ B-cell acute lymphoblastic leukemia (ALL) under the medical benefit; applies to Anthem members and providers requesting coverage.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Cablivi (caplacizumab-yhdp)Clinical medical benefit policy for use of Cablivi (caplacizumab-yhdp) for treatment of acquired thrombotic thrombocytopenic purpura (aTTP) in patients ≥12 years, including initial and continuation criteria, coding references, and exclusions.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Colony Stimulating Factor AgentsClinical coverage and medical necessity criteria for granulocyte and granulocyte-macrophage colony stimulating factor (CSF) agents used primarily to prevent or treat chemotherapy-induced febrile neutropenia and for certain mobilization/adjunctive indications; applies to Anthem medical benefit determinations.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Datroway (datopotamab deruxtecan-dlnk) — Medical Drug Clinical CriteriaClinical criteria governing prior authorization and medical necessity determinations for Datroway for adults with unresectable or metastatic HR-positive, HER2-negative breast cancer and for certain EGFR‑mutated NSCLC patients; affects providers seeking coverage under Anthem medical benefit plans.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Denosumab Agents (Prolia, Xgeva, and Biosimilars) — Clinical Coverage CriteriaClinical coverage criteria, step therapy, quantity limits, and coding for denosumab products (Prolia, Xgeva, and listed biosimilars) for osteoporosis and metabolic bone disease; applies to Anthem medical benefit reviews and prior authorization determinations.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Elzonris (tagraxofusp-erzs) — coverage criteria for BPDCNCriteria governing medical-benefit coverage and prior authorization for Elzonris (tagraxofusp-erzs) for treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN), including eligibility, dosing prerequisites, and monitoring requirements for providers and payers.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Entyvio (vedolizumab) — Medical Drug Clinical CriteriaMedical necessity and coverage criteria for intravenous and subcutaneous vedolizumab (Entyvio) for Crohn's disease, ulcerative colitis, acute GVHD, and immune checkpoint inhibitor–related GI toxicities under Anthem's medical benefit.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Gazyva (obinutuzumab) — Clinical Coverage CriteriaClinical coverage criteria for use of Gazyva (obinutuzumab) across oncology indications and lupus nephritis, specifying indications, required documentation, and coding for Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Immunoglobulins (IVIG/SCIG) — Coverage Criteria and Prior AuthorizationClinical policy governing use of intravenous and subcutaneous immunoglobulin products for medical indications; applies to Anthem medical benefit reviews and prior authorization decisions.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Kadcyla (ado-trastuzumab) coverageClinical medical policy defining prior authorization and medical necessity criteria for Kadcyla (ado-trastuzumab emtansine) across HER2-positive oncology indications including breast cancer, NSCLC, brain metastases, head & neck and salivary gland tumors for Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Keytruda (pembrolizumab) / Keytruda Qlex (pembrolizumab + berahyaluronidase alfa) coverage criteriaClinical coverage criteria for pembrolizumab (Keytruda) and subcutaneous Keytruda Qlex across multiple tumor types, including biomarker and prior‑therapy requirements used for provider requests and prior authorization decisions.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Kimmtrak (tebentafusp-tebn)Clinical criteria governing prior authorization and medical necessity determinations for Kimmtrak (tebentafusp-tebn) for treatment of HLA-A*02:01-positive adults with unresectable or metastatic uveal melanoma under the medical benefit.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Lunsumio (mosunetuzumab-axgb) and Lunsumio Velo (mosunetuzumab-axgb) - Coverage CriteriaClinical criteria and coding guidance governing prior authorization and coverage considerations for Lunsumio (IV) and Lunsumio Velo (SC) for treatment of relapsed/refractory follicular lymphoma and certain NCCN 2A B-cell lymphoma indications; applies to Anthem medical benefit reviews.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Monoclonal Antibodies to Interleukin-6Clinical coverage criteria, quantity limits, and prior authorization requirements for IL-6 receptor monoclonal antibodies (tocilizumab products and sarilumab) across multiple indications including RA, GCA, JIA, CRS, SSc-ILD, transplant rejection, and others for Anthem members.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Mozobil (plerixafor)Clinical coverage criteria for use of Mozobil (plerixafor) to mobilize hematopoietic stem cells for autologous (and select allogeneic donor) transplantation and for use during development of ex vivo gene therapy; applies to Anthem medical benefit review and prior authorization. Affects providers requesting Mozobil for eligible patients or donors.All Anthem updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-26Opdivo Qvantig (nivolumab hyaluronidase‑nvhy) — Medical Drug Clinical CriteriaMedical drug clinical criteria governing use and coverage determinations for Opdivo Qvantig (a subcutaneous formulation of nivolumab with hyaluronidase) for Anthem members; applies to clinical review and prior authorization decisions.All Anthem updates
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Tool Description
Search Anthem coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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