Oscar Clinical Guidelines

Medical and Pharmacy Clinical Guidelines describe Oscar’s evaluation of medical procedures, devices, and medications. For more information, and to access the current Oscar Clinical Guidelines, visit the Medical & Pharmacy Guidelines pages.
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These materials are used to guide utilization management decisions. The specific care and treatment ordered by your provider may vary, depending on individual needs. Clinical guidelines are approved and adopted by the Oscar insurance companies and Oscar Management Corporation (collectively, “Oscar”). These include internally developed Oscar Clinical Guidelines, guidelines licensed from MCG (Milliman Care Guidelines), technology reports licensed from Hayes, criteria licensed from CVS/Caremark, national society guidelines (e.g., NCCN, ACOG), and other evidence-based resources. Clinical guidelines are evaluated and updated at least annually.Clinical guidelines are complex and intended for use by healthcare professionals. They are not intended to provide medical advice or medical care. Medical advice and medical care should be discussed with the treating provider. Oscar Clinical Guidelines help us determine medical necessity, but do not guarantee benefit coverage. Coverage is subject to the terms and conditions of your policy and applicable state and federal law. To confirm benefit coverage or to request a copy of a clinical guideline used to support medical necessity decisions, please contact Member or Provider Services: 855-672-2755 for Oscar Plans and 855-672-2789 for Cigna+Oscar Plans.