Oscar Clinical Guidelines: Medical
Clinical guidelines are developed and adopted to establish evidence-based clinical criteria for utilization management decisions. Oscar may delegate utilization management decisions of certain services to third-party delegates, who may develop and adopt their own clinical criteria.Clinical guidelines are applicable to certain policies. Clinical guidelines are applicable to members enrolled in Medicare Advantage plans only if there are no in-force criteria for the specified service in a Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) or local coverage determination (LCD) on the date of a prior authorization request. Coverage of services is subject to the terms, conditions, limitations of a member’s policy and applicable state and federal law. Please reference the member’s policy documents (e.g., Certificate/Evidence of Coverage, Schedule of Benefits) or to confirm coverage contact 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans.Looking for our Pharmacy Guidelines? Click here. Looking for our Archived guidelines? Click here.
Upcoming Policy Changes
- Summary of Changes
- 2026 Q1 (January) P&T Summary of Changes
- 2025 Q4 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q4 (December) P&T Summary of Changes
- 2025 Q4 (November) P&T Summary of Changes
- 2025 Q4 (October) P&T Summary of Changes
- Effective 3/1/2026
- Ambulance Services (CG057, Ver. 8)
- Hearing Aids and Implants (CG001, Ver. 13)
- Effective 3/2/2026
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101, Ver. 3)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 4)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 7)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 6)
- Diabetes Equipment and Supplies (CG028, Ver. 12)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 4)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090, Ver. 4)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 6)
- Kymriah (tisagenlecleucel) (CG058, Ver. 9)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245, Ver. 2)
- Pedmark (sodium thiosulfate) (PG133, Ver. 6)
- Somatostatin Analogs - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG078, Ver. 5)
- Testosterone Replacement Therapy (PG122, Ver. 6)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 6)
- Winrevair (sotatercept-csrk) (PG207, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 9)
- Effective 4/1/2026
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 9)
- (Commercial) Preferred Physician-Administered Specialty Drugs (CG052, Ver. 34)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 4)
- Gonadotropin-Releasing Hormone Agonists for Prostate Cancer - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG085, Ver. 3)
- Ilaris (canakinumab) (PG185, Ver. 3)
- Intravitreal Corticosteroid Injections or Implants (PG271, Ver. 1)
- Syfovre (pegcetacoplan injection) (PG150, Ver. 4)
- Tepezza (teprotumumab-trbw) (PG273, Ver. 1)
- Effective 5/1/2026
- Anesthesia and Sedation in Endoscopic Procedures (CG041, Ver. 11)
- Contact Lenses and Eyeglasses (CG039, Ver. 11)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160, Ver. 3)
- Enteral and Oral Nutritional Supplements (CG011, Ver. 11)
- Hospital Beds and Accessories (CG006, Ver. 13)
- Lantidra (donislecel-jujn) (PG167, Ver. 3)
- Leqembi (lecanemab-irmb) (PG138, Ver. 5)
- Manual and Electric Breast Pumps (CG002, Ver. 12)
- Noninvasive Positive Pressure Ventilation (CG003, Ver. 14)
- Oxygen Therapy (CG005, Ver. 12)
- Papzimeos (zopapogene imadenovec-drba) (PG275, Ver. 1)
- Prescription Digital Therapeutics (PG142, Ver. 3)
- Pressure-Reducing Support Surfaces (CG007, Ver. 12)
- Skilled Nursing Facility Care (CG042, Ver. 12)
- Varicose Vein Treatment (CG004, Ver. 14)
- Wearable Cardioverter-Defibrillator Devices (CG019, Ver. 13)
- Effective 6/1/2026
- Izervay (avancincaptad pegol) (PG168, Ver. 4)
- Prevymis (letermovir) (PG280, Ver. 1)
- Ycanth (cantharidin) (PG162, Ver. 5)
Medical Guidelines
- Acupuncture (CG013, Ver. 11)
- Adakveo (crizanlizumab) (PG193, Ver. 2)
- Allergy (Allergen) Immunotherapy (CG059, Ver. 7)
- Ambulatory Cardiac Event Monitoring (CG032, Ver. 11)
- Ambulance Services (CG057, Ver. 7)
- Amvuttra (vutrisiran) (PG264, Ver. 2)
- Anesthesia and Sedation in Endoscopy (CG041, Ver. 10)
- Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008, Ver. 9)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136, Ver. 3)
- Authorization Duration Exception-REG (PG269, Ver. 2)
- Autonomic Testing (CG026, Ver. 11)
- Balloon Ostial Dilation (CG018, Ver. 11)
- Bariatric Surgery and Revision of Bariatric Surgery (Adults) (CG008, Ver. 11)
- Bariatric Surgery and Revision of Bariatric Surgery (Adolescents/ Ages 13 - 17) (CG009, Ver. 11)
- Benign Prostatic Hyperplasia Procedures (CG031, Ver. 11)
- Benlysta (belimumab) (PG014, Ver. 8)
- Beyfortus (nirsevimab-alip) and Enflonsia (clesrovimab-cfor) (PG180, Ver. 3)
- Bioengineered Skin and Soft Tissue Substitutes (CG030, Ver. 12)
- Botulinum Toxin (CG033, Ver. 15)
- Breast Imaging (CG027, Ver. 11)
- Breast Procedures (CG036, Ver. 12)
- Briumvi (ublituximab) (PG134, Ver. 5)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 6)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 4)
- Collagenase Ointment (Santyl) (PG141, Ver. 3)
- Colorectal Cancer Screening (CG024, Ver. 11)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 33)
- Commercial Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria
- Agents for Amyloidosis-Associated Polyneuropathy - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG109, Ver. 2)
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG120, Ver. 2)
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101, Ver. 2)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 3)
- Antiemetics - Substance P/Neurokinin 1 (NK1) Antagonist (i.e., Fosaprepitant Products) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG103, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 8)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 3)
- Biologics for Chronic Respiratory and Allergic Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100, Ver. 4)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 5)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 3)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090, Ver. 3)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 3)
- Gonadotropin-Releasing Hormone Agonists for Prostate Cancer - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG085, Ver. 2)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 5)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 4)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097, Ver. 3)
- Somatostatin Analogs - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG078, Ver. 4)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 4)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 5)
- Concomitant use of biologics and tsDMARDs (CG064, Ver. 6)
- Contact Lenses and Eyeglasses (CG039, Ver. 10)
- Coronavirus Disease (COVID-19) Antibody Testing (CG077, Ver. 3)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050, Ver. 9)
- Diabetes Equipment and Supplies (CG028, Ver. 11)
- Diagnosis and Treatment of Infertility (CG016, Ver. 13)
- Dupixent (dupilumab) (PG026, Ver. 15)
- Durysta (bimatoprost intracameral implant) (CG116, Ver. 3)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Enteral and Oral Liquid Nutritional Supplements (CG011)
- Erectile Dysfunction (CG037, Ver. 13)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012, Ver. 12)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 5)
- Forzinity (elamipretide) (PG274, Ver. 1)
- Glaucoma Surgery (CG034, Ver. 11)
- Growth Hormones (Lonapegsomatropin, Somapacitan, Somatropin, Somatrogon) (PG049, Ver. 8)
- Hearing Aids and Implants (CG001, Ver. 12)
- Hemgenix (etranacogene dezaparvovec) (CG075, Ver. 5)
- Home Care - Home Health Aides (HHA) (CG022, Ver. 11)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020, Ver. 11)
- Home Care - Physical Therapy (PT) and Occupational Therapy (OT) (CG021, Ver. 11)
- Home Care - Speech Language Pathology (SLP) Services (CG023, Ver. 11)
- Hospital Beds and Accessories (CG006, Ver. 12)
- Hyperbaric Oxygen Therapy (CG014, Ver. 11)
- Hypoglossal Nerve Stimulation (CG065, Ver. 6)
- iDose TR (travoprost intracameral implant) (CG115, Ver. 4)
- Ilaris (canakinumab) (PG185)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 1)
- Infertility Injectable Agents (PG119, Ver. 4)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 16)
- Intraoperative Neuromonitoring (CG045, Ver. 9)
- Ilumya (tildrakizumab-asmn) (CG053, Ver. 8)
- Injectable Iron Supplements (PG196, Ver. 5)
- Izervay (avancincaptad pegol) (PG168, Ver. 3)
- Kebilidi (eladocagene exuparvovec-tneq) (PG259, Ver. 1)
- Kisunla (donanemab-azbt) (PG238, Ver. 2)
- Kymriah (tisagenlecleucel) (CG058, Ver. 8)
- Lamzede (velmanase alfa-tycv) (PG146, Ver. 3)
- Lantidra (donislecel-jujn) (PG167)
- Lemtrada (Alemtuzumab) (PG226, Ver. 2)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 3)
- Home Births and Birth Centers (CG038 Ver. 11)
- Leqembi (lecanemab-irmb) (PG138)
- Long-Term Acute Care Hospital (LTACH) (CG062, Ver. 7)
- Luxturna (voretigene neparvovec-rzyl) (CG060, Ver. 7)
- Lyfgenia (lovotibeglogene autotemcel) (CG114, Ver. 3)
- Manual and Electric Breast Pumps (CG002, Ver. 11)
- Medical Nutrition Therapy (Dietary Evaluation & Counseling) (CG010, Ver. 11)
- Methotrexate Injectable Solution (PG249, Ver. 3)
- Mitoxantrone (Novantrone) (PG126, Ver. 4)
- Negative Pressure Wound Therapy and Negative Pressure Infusion/Instillation Therapy for the Treatment of Complicated Wounds for Outpatient and Home Care Settings (CG068, Ver. 5)
- NexoBrid (anacaulase-bcdb) (CG112, Ver. 3)
- Niktimvo (axatilimab) (PG252, Ver. 2)
- Noninvasive Positive Pressure Ventilation (CG003, Ver. 13)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235, Ver. 4)
- Omisirge (omidubicel-onlv) (PG149, Ver. 3)
- Optical Coherence Tomography (OCT) (CG025, Ver. 11)
- Outpatient Physical Therapy (PT) and Occupational Therapy (OT) (CG044, Ver. 9)
- Oxygen Therapy (CG005, Ver. 11)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048, Ver. 9)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047, Ver. 9)
- Pain Management: Sacroiliac Intra-Articular Joint Injections (CG056, Ver. 8)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245)
- Pedmark (sodium thiosulfate) (PG133)
- PiaSky (crovalimab-akkz) (PG262, Ver. 1)
- Pneumatic Compression Devices (CG049, Ver. 10)
- Prenatal Testing (CG043, Ver. 12)
- Prescription Digital Therapeutics (PG142)
- Pressure-Reducing Support Surfaces (CG007, Ver. 11)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068, Ver. 7)
- Qalsody (tofersen) (PG151, Ver. 4)
- Quantity Limit Exception Criteria (PG200, Ver. 3)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 2)
- Rezzayo (rezafungin) (PG145, Ver. 4)
- Roctavian (valoctocogene roxaparvovec-rvox) (PG163, Ver. 3)
- Rystiggo (rozanolixizumab-noli) (PG190, Ver. 2)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017, Ver. 15)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046, Ver. 11)
- Skilled Nursing Facility Care (CG042, Ver. 11)
- Skysona (elivaldogene autotemcel) (CG074, Ver. 4)
- Soliris (eculizumab) (PG188, Ver. 3)
- Spevigo (spesolimab-sbzo) (CG071, Ver. 5)
- Spravato (esketamine) (PG257, Ver. 1)
- Spinal Orthoses (Back Braces) (CG051, Ver. 9)
- Step Therapy Exception-REG (PG270, Ver. 2)
- Syfovre (pegcetacoplan injection) (PG150)
- Tevimbra (tislelizumab) (PG210, Ver. 2)
- Thyrogen (thyrotropin alfa) (PG140, Ver. 3)
- Total Hip Arthroplasty (Replacement) (CG070, Ver. 7)
- Total Knee Arthroplasty (Replacement) (CG069, Ver. 7)
- Total Shoulder Arthroplasty (Replacement) and Reverse Total Shoulder Arthroplasty (CG076, Ver. 6)
- Transcranial Doppler (CG035, Ver. 11)
- Treatment and Removal of Benign Skin Lesions (CG015, Ver. 11)
- Tysabri (natalizumab) (PG195, Ver. 4)
- Tzield (teplizumab-mzwv) (CG072, Ver. 4)
- Ultomiris (ravulizumab-cwvz) (PG189, Ver. 3)
- Varicose Vein Treatment (CG004, Ver. 13)
- Varubi (rolapitant) (PG178, Ver. 3)
- Viscosupplementation for Osteoarthtiris (CG054, Ver. 9)
- Vyjuvek (beremagene geperpavec-svdt) (PG147, Ver. 3)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (PG191, Ver. 3)
- Wearable Cardioverter-Defibrillator Devices (CG019, Ver. 12)
- Winrevair (sotatercept-csrk) (PG207, Ver. 2)
- Ycanth (cantharidin) (PG162, Ver. 4 )
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 8)
- Zolgensma (onasemnogene abeparvovec-xioi) (CG061, Ver. 7)
- Zynteglo (betibeglogene autotemcel) (CG073, Ver. 4)
Adopted Guidelines
- American Society of Addiction Medicine (ASAM)
- American Specialty Health (ASH)
- Child and Adolescent Level of Care/Service Intensity Utilization System (CALOCUS-CASII)
- Child & Adolescent Service Intensity Instrument (CASII)
- MCG Guidelines
- Evicore
- Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS)
- Optum Behavioral Health Clinical Criteria
- Progeny
- The Early Childhood Service Intensity Instrument (ECSII)
- The World Professional Association for Transgender Health Standards of Care