Anthem Prior Authorization Lookup
Latest Anthem prior authorization updates25
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Medicaid-Approved Preferred Drug List (partial formulary entries)Lists formulary entries and coverage notes (OTC, PA, QL, DO, AL, SP) for Anthem Medicaid in North Carolina; affects prescribers, pharmacies, and prior authorization staff responsible for dispensing and reimbursement.All Anthem updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Drug list — Five Tier Drug Plan (Formulary)Defines the prescription drug list (formulary) structure, tiering, and basic member-facing rules for coverage, prior authorization, step therapy, quantity limits, and specialty distribution for Anthem members. Affects members and providers using the Anthem prescription benefit and pharmacy administrators.All Anthem updates
- Prior AuthClinical/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
- Prior AuthAdministrative/Operational PolicyEff. 2026-04-01Georgia Local Precertification/Prior Authorization ListLists services and CPT codes that require precertification/prior authorization for local fully‑insured Anthem Blue Cross and Blue Shield members in Georgia and certain ASO members; excludes BlueCard, Medicare Advantage, Medicaid, Medicare Supplement, and FEP members.All Anthem updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2026-03-26Hereditary Angioedema AgentsClinical coverage and prior authorization criteria for medical-benefit hereditary angioedema (HAE) drugs for prophylaxis and treatment, including age limits, diagnostic verification, approval durations, and quantity limits. Affects providers prescribing or requesting authorization for HAE agents for Anthem members.All Anthem updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2026-03-26Melanoma Vaccines (Imlygic/talimogene laherparepvec)Defines medical necessity and prior authorization criteria for use of Imlygic (talimogene laherparepvec) and other melanoma vaccines under the medical benefit for members; applies to coverage decisions for melanoma and select Merkel cell carcinoma indications.All Anthem updates
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/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
- Prior AuthClinical/Medical PolicyEff. 2026-03-26Orencia (abatacept) — Clinical Medical Policy (coverage criteria)Clinical medical policy governing prior authorization, step therapy, quantity limits, and coverage criteria for Orencia (abatacept) for Anthem members, including indications such as rheumatoid arthritis, polyarticular juvenile idiopathic arthritis, psoriatic arthritis, GVHD prophylaxis, chronic GVHD, and immune checkpoint inhibitor–related toxicities.All Anthem updates
1–25 of 433
1 / 18
Tool Description
Search Anthemprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Prior Authorization by Payer
Go deeper
Explore OpenPayer Data
Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Coverage Criteria LookupSearch payer coverage criteria and medical necessity requirements by drug, procedure, or payer.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.