Clinical Criteria

Carelon Medical Benefits Management Clinical guidelines (IFP/SG Only)

Bright Health Clinical Criteria

Medical Policies

Ambulance Services - Medical Transportation
Medical | IFP, Small Group, Medicare Advantage

Aquired Brain Injury (TX)
Medical | TX | IFP

Adult Sleep Studies
Medical | IFP, Medicare Advantage

Arthroscopic Knee Surgery
Medical | IFP, Small Group, Medicare Advantage

Autologous Chondrocyte Implantation (ACI)
Medical | IFP, Small Group, Medicare Advantage

Bariatric Surgery
Medical | IFP, Medicare Advantage

Cervical Spine
Medical | IFP, Medicare Advantage

Continuity of Care/Transition of Care
Medical | IFP, Small Group, Medicare Advantage

Criterion Modification Policy

Dental Services
Medical | IFP, Small Group, Medicare Advantage

Drug Testing
Medical | IFP, Medicare Advantage

Gender Dysphoria Services
Medical | IFP, Small Group

Genetic Testing
Medical | IFP, Medicare Advantage

Home Health Services
Medical | IFP, Medicare Advantage

Hospital Stay Requirement SNF
Medical | Medicare Advantage

Intraoperative Neuromuscular Monitoring for Spinal Surgery
Medical Policy | IFP, Small Group

Investigational or Experimental Services and Clinical Trials
Medical | IFP, Small Group, Medicare Advantage

Liver Fibrosis Serum Testing
Medical | IFP, Small Group, Medicare Advantage

Lumbar Spine
Medical | IFP, Small Group

Short Stay Admissions and Outpatient Hospital Observation
Medical | IFP, Small Group, Medicare Advantage

Pediatric Sleep Studies
Medical | IFP

Pulsed Dye Laser
Medical | IFP, Medicare Advantage

Readmission Review
Medical Pharmacy | Medicare Advantage

Site of Service
Medical Pharmacy | Medicare Advantage

Sacroiliac Joint Infections
Medical Policy | IFP, Small Group, Medicare Advantage

Sepsis and Septic Shock
Medical Policy | MA

Skilled Nursing Facility Services
Medical | IFP, Medicare Advantage

Temporomandibular Joint (TMJ) Disorders
Medical | IFP, Small Group, Medicare Advantage

Total Hip Arthroplasty
Medical | IFP

Total or Partial Knee Arthroplasty
Medical | IFP, Medicare Advantage

Total or Partial Knee Arthroplasty
Medical | IFP, Medicare Advantage

Tumor Treating Fields - Optune
Medical | IFP, Small Group, Medicare Advantage

Varicose Veins (Clinical Criteria Modification)
Medical Pharmacy Policy | IFP, SG, MA

Medical Pharmacy Policies

Abecma - idecabtagene vicleucel
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Actemra - tocilizumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Adakveo - crizanlizumab-tmca
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Aduhelm - aducanumab-avwa
Medical Pharmacy | Medicare Advantage

Alimta - pemetrexed
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Aloxi - palonosetron
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Alpha-1-Proteinase Inhibitors: Aralast/Prolastin/Zemaira/Glassia
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Amvuttra
Medical Pharmacy | IFP, SG, Medicare Advantage

Breyanzi - lisocabtagene maraleucel
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Briumvi
Medical Pharmacy Policy | IFP, SG, MA

Cabenuva - cabotegravir and rilpivirine
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Carvykti
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Cerezyme (imiglucerase))
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Cimzia - certolizumab pegol
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Clotting Disorder Therapy
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Cosela - trilaciclib
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Cresemba - isavuconazonium sulfate
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Dalvance - dalbavancin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Duchenne Muscular Dystrophy (DMD)
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Elahere
Medical Pharmacy Policy | IFP, SG, MA

Emend - fosaprepitant dimeglumine
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Empaveli - pegcetacoplan
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Enjaymo
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Entyvio - vedolizumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Evenity - romosozumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Evkeeza - evinacumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Fasenra - benralizumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Feraheme
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Fyarro - sirolimus albumin-bound
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Givlaari - givosiran
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Hemgenix
Medical Pharmacy Policy | IFP, SG, MA

Hyaluronate Injections for Osteoarthritis of the Knee
Medical Pharmacy | IFP, Small Group

Ilaris - canakinumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Ilumya - tildrakizumab-asmn
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Imjudo
Medical Pharmacy Policy | IFP, SG, MA

Intravenous Immune Globulins (IVIG)
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Intravitreal Injections/Implants
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Isodax_romidepsin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Jemperli - dostarlimab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Khapzory - levoleucovorin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Kimmtrack - tebentafusp-tebn
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Krystexxa - pegloticase
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Kymriah - tisagenlecleucel
Medical Pharmacy | IFP, Medicare Advantage

Leqembi
Medical Pharmacy Policy | IFP, SG, MA

Leqvio - inclisiran
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Lunsumio
Medical Pharmacy Policy | IFP, SG, MA

Lupron Depot-Lupron Depot-Ped Eligard-Fensolvi-Camcevi - leuprolide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Luxturna - voretigene neparvovec
Medical Pharmacy | IFP, Medicare Advantage

Mepsevii - vestronidase alfa-vjbk
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Nexviazyme - avalglucosidase alfa-ngpt
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Nulibry - fosdenopterin hydrobromide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Nulojix - belatacept
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Off Label Indications
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Opdualag
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Orencia - abatacept
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Padcev - enfortumab vedotin-ejfv
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Pepaxto - melphalan flufenamide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Pulmonary Arterial Hypertension
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Reblozyl - luspatercept-aamt
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Relizorb - immobilized lipase
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Rybrevant - amivantamab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Saphnelo - anifrolumab-fnia
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Sarclisa - isatuximab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Signifor LAR - pasireotide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Simponi ARIA - golimumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Skysona
Medical Pharmacy | IFP, SG, MA

Somatuline Depot - lanreotide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Spevigo
Medical Pharmacy | IFP, SG, MA

Spinraza - nusinersen
Medical Pharmacy | IFP, Medicare Advantage

Stelara - ustekinumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Subcutaneous Immune Globulins (SCIG)
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Sunlenca
Medical Pharmacy Policy | IFP, SG, MA

Supprelin LA - histrelin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Synagis - palivizumab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Takhyzro - lanadelumab-flyo
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Tecartus - brexucabtagene autoleucel
Medical Pharmacy | IFP, Medicare Advantage

Tecvayli
Medical Pharmacy Policy | IFP, SG, MA

Tepezza - teprotumumab-trbw
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Tezspire - tezepelumab-ekko
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Tivdak - tisotumab vedotin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Trelstar
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Triptodur - triptorelin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Tzield
Medical Pharmacy | IFP, SG, MA

Vimizim - elosulfase alfa
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Vyepti - eptinezumab-jjmr
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Vyvgart - efgartigimod alfa-fcab
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Xenpozyme
Medical Pharmacy | IFP, SG, MA

Yescarta - axicabtagene ciloleucel
Medical Pharmacy | IFP, Medicare Advantage

Zepzelca - lurbinectedin
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Zilretta - triamcinolone acetonide
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Zolgensma - onasemnogene abeparvovec-xioi
Medical Pharmacy | IFP, Medicare Advantage

Zulresso - brexanolone
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Zynlonta - loncastuximab tesirine
Medical Pharmacy | IFP, Small Group, Medicare Advantage

Zynteglo (betibeglongene autotemcel)
IFP, SG, MA | Medical Pharmacy Policy

Step Therapy

Policies with Step Therapy Requirements:

Part B Step Therapy Drug List
Step Therapy | Medicare Advantage

Antineoplastic – rituximab
Medical Pharmacy | IFP & Small Group

Antineoplastic – bevacizumab
Medical Pharmacy | IFP, Small Group

Antineoplastic – bevacizumab
Medical Pharmacy | Medicare Advantage

Antineoplastic - rituximab
Medical Pharmacy | Medicare Advantage

Antineoplastic – trastuzumab
Medical Pharmacy | IFP, Small Group

Antineoplastic – trastuzumab
Medical Pharmacy | Medicare Advantage

Anti-inflammatory infliximab
Medical Pharmacy | Medicare Advantage

Anti-inflammatory infliximab
Medical Pharmacy | IFP, Small Group

Colony Stimulating Factors – Long Acting
Medical Pharmacy | IFP, Small Group

Colony Stimulating Factors Long Acting
Medical Pharmacy | Medicare Advantage

Colony Stimulating Factors – Short Acting
Medical Pharmacy | IFP, Small Group

Colony Stimulating Factors – Short Acting
Medical Pharmacy | Medicare Advantage

Hyaluronate Injections for Osteoarthritis of the Knee
Step Therapy | Medicare Advantage