Jan. 22, 2026
Our medical necessity reviews are conducted using evidence-based criteria. The reviews help promote quality of care and optimal outcomes for our members.
New resource for you: We have a new training that provides an overview of clinical review criteria used in our reviews. The training provides helpful information regarding applicable medical policies and pharmacy guidelines.
You can access the training here or through links on these pages:
- Prior authorization support materials for commercial and government programs
- On-demand training section of webinars and workshops
This material is for informational purposes only and is not a substitute for the independent medical judgment of a physician or other health care provider. References to other third party sources or organizations are not a representation, warranty or endorsement of such organizations. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit, and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.