Oscar Clinical Guidelines: Archived
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. The clinical guidelines are applicable to all commercial policies. 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. You can find the active guidelines below:
Archived Medical and Pharmacy Policies
- Acupuncture (CG013)
- Acupuncture (CG013, Ver. 10)
- Aduhelm (aducanumab-avwa) (PG139)
- Allergen Sublingual Immunotherapy (SLIT) (PG093)
- Ambulatory Cardiac Event Monitoring (CG032)
- Ambulatory Cardiac Event Monitoring (CG032, Ver. 10)
- Amvuttra (vutrisiran) (PG264, Ver. 1)
- Antidiabetic Agents - Glucagon-like Peptide-1 (GLP-1) Receptor Agonists (PG152, Ver. 5)
- Antidiabetic Agent - SymlinPen (pramlintide acetate) (PG156, Ver 3.)
- Aptiom (eslicarbazepine acetate) (PG174, Ver. 2)
- Aripiprazole oral disintegrating tablet, solution (PG173, Ver. 3)
- Asenapine (Saphris) (PG058, Ver 6.)
- Authorization Duration Exception-REG (PG269, Ver. 1)
- Autonomic Testing (CG026)
- Autonomic Testing (CG026, Ver. 10)
- Auvelity (Dextromethorphan and Bupropion) (PG128, Ver. 3)
- Azelaic acid 15% gel (PG059, Ver. 6)
- Balloon Ostial Dilation (CG018)
- Balloon Ostial Dilation (CG018, Ver. 10)
- Bariatric Surgery (Adolescents) (CG009)
- Bariatric Surgery (Adolescents: Ages 13 - 17) (CG009, Ver. 10)
- Bariatric Surgery (Adults) (CG008)
- Bariatric Surgery (Adults) (CG008, Ver. 10)
- Benign Prostatic Hyperplasia Procedures (CG031)
- Benign Prostatic Hyperplasia Procedures (CG031, Ver. 10)
- Benlysta (belimumab) (PG014, Ver. 7)
- Benzodiazepines for Acute Repetitive Seizures or Seizure Clusters (PG1254)
- Beqvez (fidanacogene elaparvovec) (CG118)
- Beyfortus (nirsevimab-alip) (PG180)
- Breast Imaging (CG027)
- Breast Imaging (CG027, Ver. 10)
- Breast Procedures (CG036)
- Breast Procedures (CG036, Ver. 11)
- Brimonidine/Timolol (Combigan) (PG103)
- Briumvi (ublituximab) (PG134)
- Briviact (brivaracetam) Tablet, Solution (PG172, Ver. 2)
- Caplyta (lumateperone) (PG175)
- Casgevy (exagamglogene autotemcel) (CG113)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 3)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 2)
- CeQur Simplicity Insulin Delivery System (PG192)
- clomiphene (Clomid) (PG104)
- clomiphene (Clomid) (PG104, Ver. 5)
- Collagenase Ointment (Santyl) (PG141)
- Combination Products for Treatment of Helicobacter pylori (PG199)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 3)
- Continuous Glucose Monitors (CGMs) Prescription Products (PG121, Ver. 6)
- Cromolyn Sodium Oral Concentrate (PG087, Ver. 6)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050, Ver. 8)
- Dipentum (olsalazine sodium) (PG244, Ver. 1)
- Direct Acting Antiviral Agents for Hepatitis C (PG045, Ver. 6)
- Doxylamine/Pyridoxine (Bonjesta, Diclegis) (PG096, Ver. 5)
- Dupixent (dupilumab) (PG026)
- Dupixent (dupilumab) (PG026, Ver. 13)
- Durysta (bimatoprost intracameral implant) (CG116)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012, Ver. 11)
- Fetzima (levomilnacipran) (PG063, Ver. 6)
- Fycompa (perampanel) (PG176, Ver. 2)
- Glaucoma Surgery (CG034)
- Glaucoma Surgery (CG034, Ver. 10)
- Infertility Treatment (CG016)
- Diagnosis and Treatment of Infertility (CG016, Ver. 12)
- Home Care - Home Health Aides (CG022)
- Home Care - Home Health Aides (HHA) (CG022, Ver. 10)
- Home Care - Physical Therapy/Occupational Therapy (CG021)
- Home Care - Physical Therapy (PT) and Occupational Therapy (OT) (CG021, Ver. 10)
- Home Care - Speech Language Pathology (CG023)
- Home Care - Speech Language Pathology (SLP) Services (CG023, Ver. 10)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020)
- Home Care - Skilled Nursing Care (RN, LVN/LPN) (CG020, Ver. 10)
- Hyperbaric Oxygen Therapy (CG014)
- Hyperbaric Oxygen Therapy (CG014, Ver. 10)
- Hypoglossal Nerve Stimulation (CG065)
- Hypoglossal Nerve Stimulation (CG065, Ver. 5)
- iDose TR (travoprost intracameral implant) (CG115, Ver. 3)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Intraoperative Neuromonitoring (CG045)
- Intraoperative Neuromonitoring (CG045, Ver. 8)
- Lacosamide (Vimpat) (PG056, Ver. 6)
- Lamotrigine ER (Lamictal XR) (PG055, Ver. 6)
- Lamotrigine Orally Disintegrating Tablet (PG083, Ver. 6)
- Lamzede (velmanase alfa-tycv) (PG146, Ver. 2)
- Lemtrada (Alemtuzumab) (PG226)
- Lenmeldy (atidarsagene autotemcel) (CG117)
- Medical Nutrition Therapy (CG010)
- Medical Nutrition Therapy (Dietary Evaluation & Counseling) (CG010, Ver. 10)
- Memantine (Namenda) (PG213, Ver. 1)
- Methotrexate Injectable Solution (PG249, Ver. 1)
- Niktimvo (axatilimab) (PG252)
- Non-Formulary Mental Health Products Criteria (PG265, Ver. 1)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235)
- Optical Coherence Tomography (OCT) (CG025, Ver. 10)
- Orgovyx (relugolix) (PG089, Ver. 6)
- Outpatient Physical Therapy & Occupational Therapy (CG044)
- Outpatient Physical Therapy (PT) and Occupational Therapy (OT) (CG044, Ver. 8)
- Oxbryta (voxelotor) (PG114)
- Oxbryta (voxelotor) (PG114, Ver. 3)
- Oxiconazole (Oxistat 1%) (PG100)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048)
- Pain Management: Epidural Steroid Injections, Selective Nerve Root Blocks (SNRB), and Intradiscal Steroid Injections (CG048, Ver. 8)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047)
- Pain Management: Facet Joint Injections/Medial Branch Blocks and Radiofrequency Facet Denervation (CG047, Ver. 8)
- Phenoxybenzamine (PG054, Ver. 6)
- Prescription Drugs for Serious Mental Illnesses-REG (PG171, Ver. 2)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 1)
- Relyvrio (Sodium Phenylbutyrate/Taurursodiol) (PG129)
- Relyvrio (Sodium Phenylbutyrate/Taurursodiol) (PG129, Ver. 2)
- Restasis (cyclosporine ophthalmic emulsion 0.05%) (PG025, Ver. 7)
- Rivastigmine (Exelon) (PG212, Ver. 1)
- Sancuso (granisetron) Patch (PG007, Ver. 7)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017)
- Sex Reassignment Surgery (Gender Affirmation Surgery) and Non-Surgical Services (CG017, Ver. 14)
- Sirturo (bedaquiline) (PG242)
- Skilled Nursing Facility Care (CG042)
- Skilled Nursing Facility Care (CG042, Ver. 10)
- Testosterone Replacement Therapy (PG122)
- Tevimbra (tislelizumab) (PG210)
- Transcranial Doppler (CG035)
- Transcranial Doppler (CG035, Ver. 10)
- Treatment and Removal of Benign Skin Lesions (CG015, Ver. 10)
- Tysabri (natalizumab) (PG195, Ver. 3)
- Ultomiris (ravulizumab-cwvz) (PG189, Ver. 2)
- Varubi (rolapitant) (PG178, Ver. 2)
- Velphoro (sucroferric oxyhydroxide) (PG179)
- Vemlidy (tenofovir alafenamide) (PG010)
- Verkazia (cyclosporine ophthalmic emulsion) 0.1% (PG236, Ver. 1)
- Vesicular Monoamine Transporter Type 2 (VMAT2) Inhibitors (PG144)
- Vowst (fecal microbiota spores, live-brpk) (PG241, Ver. 1)
- Xdemvy (lotilaner) (PG161)
- Xifaxan (rifaximin)(PG022)