Oscar Clinical Guidelines: Medical

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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 Pharmacy Guidelines? Click here.

Medical Guidelines

                                                    • PY24 Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria
                                                      • Agents for Autoimmune Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086)
                                                      • Bevacizumab (Alymsys, Avastin, Avzivi, Mvasi, Vegzelma, Zirabev) for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083)
                                                      • Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088)
                                                      • Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098)
                                                      • Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084)
                                                      • Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG91)
                                                      • Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090)
                                                      • Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089)
                                                      • Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092)
                                                      • Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093)
                                                      • Gonadotropin-Releasing Hormone Agonists for Prostate Cancer - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG085)
                                                      • Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094)
                                                      • Immunotherapies for Reactive and Obstructive Airway Diseases - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100)
                                                      • Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087)
                                                      • Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107)
                                                      • Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079)
                                                      • Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG095)
                                                      • Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096)
                                                      • Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097)
                                                      • Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081)
                                                      • Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080)
                                                      • Somatostatin Analogs - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG078)
                                                      • Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082)
                                                      • Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099)

                                                                                                                                                                                                              Adopted Guidelines