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 memberβs policy and applicable state and federal law. Please reference the memberβs 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
- 2025 Q3 Clinical Advisory Subcommittee (CAS) Summary of Changes
- 2025 Q3 (September) P&T Summary of Changes
- 2025 Q3 (August) P&T Summary of Changes
- 2025 Q3 (July) P&T Summary of Changes
- 2025 Q2 (June) P&T Summary of Changes
- 2025 Q2 Clinical Advisory Subcommittee (CAS) Summary of Changes
- Effective 12/01/2025
- Amvuttra (vutrisiran) (PG264, Ver. 1)
- Authorization Duration Exception-REG (PG269, Ver. 2)
- Benlysta (belimumab) (PG014, Ver. 8)
- iDose TR (travoprost intracameral implant) (CG115, Ver. 4)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 16)
- Methotrexate Injectable Solution (PG249, Ver. 3)
- Optical Coherence Tomography (OCT) (CG025, Ver. 11)
- Rebyota (fecal microbiota, live - jslm) (PG240, Ver. 2)
- Treatment and Removal of Benign Skin Lesions (CG015, Ver. 11)
- Tysabri (natalizumab) (PG195, Ver. 4)
- Varubi (rolapitant) (PG178, Ver. 3)
- Effective 1/1/2026
- Amvuttra (vutrisiran) (PG264, Ver. 2)
- Anti-migraine Agents: Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008, Ver. 9)
- 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)
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG120, Ver. 2)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 6)
- Commercial Preferred Physician-Administered Specialty Drugs (CG052, Ver. 33)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 3)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 3)
- Infertility Injectable Agents (PG119, Ver. 4)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 4)
- Injectable Iron Supplements (PG196, Ver. 5)
- Kisunla (donanemab-azbt) (PG238, Ver. 2)
- Kymriah (tisagenlecleucel) (CG058, Ver. 8)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097, Ver. 3)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 4)
- Site-of-Service (Site-of-Care) (Infusion Therapy & Physician-Administered Drugs) (CG046, Ver. 11)
- Skyrizi (risankizumab) (PG266, Ver. 1)
- Step Therapy Exception-REG (PG270, Ver. 1)
- Tremfya (guselkumab) (PG250, Ver. 4)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 5)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa and hyaluronidase-qvfc) (PG191, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063, Ver. 8)
- Effective 2/1/2026
- Bioengineered Skin and Soft Tissue Substitutes (CG030, Ver. 12)
- Colorectal Cancer Screening (CG024, Ver. 11)
- Coronavirus Disease (COVID-19) Antibody Testing (CG077, Ver. 3)
- Erectile Dysfunction (CG037, Ver. 13)
- Home Births and Birth Centers (CG038 Ver. 11)
- Long-Term Acute Care Hospital (LTACH) (CG062, Ver. 7)
- 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)
- Pain Management: Sacroiliac Intra-Articular Joint Injections (CG056, Ver. 8)
- Pneumatic Compression Devices (CG049, Ver. 10)
- Prenatal Testing (CG043, Ver. 12)
- Spinal Orthoses (Back Braces) (CG051, Ver. 9)
- 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)
- Effective 3/2/2026
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245, Ver. 2)
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)
- Anesthesia and Sedation in Endoscopy (CG041)
- Antineoplastics - Cyclophosphamide Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Policy (CG120, Ver. 1)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 7)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 3)
- Anti-migraine Agents/ Calcitonin Gene-Related Peptide (CGRP) Antagonists and Serotonin Receptor 5-HT1F Agonists (PG008)
- Approved and Accepted Off-label Medical Necessity Criteria for Products, Drugs and Biologicals (PG136, Ver. 3)
- Authorization Duration Exception-REG (PG269, Ver. 1)
- 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)
- Beyfortus (nirsevimab-alip) and Enflonsia (clesrovimab-cfor) (PG180, Ver. 3)
- Bioengineered Skin and Soft Tissue Substitutes (CG030)
- Botulinum Toxin (CG033, Ver. 15)
- Breast Imaging (CG027, Ver. 11)
- Breast Procedures (CG036, Ver. 12)
- Breast Pumps - Manual and Electric (CG002)
- Briumvi (ublituximab) (PG134, Ver. 5)
- Carvykti (ciltacabtagene autoleucel; cilta-cel) (CG067, Ver. 5)
- Casgevy (exagamglogene autotemcel) (CG113, Ver. 3)
- Collagenase Ointment (Santyl) (PG141, Ver. 3)
- Colorectal Cancer Screening (CG024)
- (Commercial) Preferred Physician-Administered Specialty Drugs (CG052, Ver. 32)
- PY25 Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (effective thru 12/31/2025)
- Agents for Amyloidosis-Associated Polyneuropathy - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG109, Ver. 1)
- Antiemetics - Substance P/Neurokinin 1 (NK1) Antagonist (i.e., Fosaprepitant Products) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG103, Ver. 1)
- Antineoplastics - Bendamustine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG102, Ver. 1)
- Antineoplastics - Bevacizumab for Cancer Indications - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG083, Ver. 3)
- Antineoplastics - Gemcitabine Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG104, Ver. 2)
- Antineoplastics - HER2-Targeted Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG101, Ver. 1)
- Antineoplastics - Pemetrexed Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG105, Ver. 2)
- Antineoplastics - Proteosome Inhibitors (i.e., bortezomib, carfilzomib) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG106, Ver. 1)
- Antineoplastics - Trastuzumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG082, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Biologics for Autoimmune and Inflammatory Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG086, Ver. 6)
- Antineoplastic and Immunomodulating Agents - Infliximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG087, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Rituximab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG081, Ver. 2)
- Antineoplastic and Immunomodulating Agents - Tocilizumab Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG108, Ver. 2)
- Biologics for Chronic Respiratory and Allergic Conditions - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG100, Ver. 3)
- Botulinum Toxins - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG088, Ver. 3)
- Complement Inhibitors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG098, Ver. 4)
- Erythropoiesis-Stimulating Agent (ESA) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG084, Ver. 2)
- Factor IX Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG089, Ver. 2)
- Factor VIII (Long-Acting) Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG090, Ver. 2)
- Factor VIII Antihemophilic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG091, Ver. 2)
- Follicle Stimulating Hormone (FSH) Products - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG092, Ver. 2)
- Gaucher's Disease Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG093, Ver. 2)
- 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. 3)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 2)
- Long-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG079, Ver. 2)
- Long-Acting Reversible Contraceptives - Medical Benefit Preferred Physician- Administered Drug Exceptions Criteria (CG095, Ver. 3)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 3)
- Prostacyclin Analogs/Receptor Agonists for Pulmonary Hypertension (PAH) - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG097, Ver. 2)
- Short-Acting Granulocyte Colony-Stimulating Factors - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG080, Ver. 3)
- Somatostatin Analogs - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG078, Ver. 4)
- Vascular Endothelial Growth Factor (VEGF) Inhibitor Ophthalmic Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG099, Ver. 4)
- Concomitant use of biologics and tsDMARDs (CG064, Ver. 6)
- Contact Lenses and Eyeglasses (CG039)
- COVID-19 Antibody Testing (CG077)
- Deep Brain Stimulation (DBS) and Responsive Neurostimulation (RNS) (CG050, Ver. 9)
- Diabetes Equipment and Supplies (CG028)
- Diagnosis and Treatment of Infertility (CG016, Ver. 13)
- Dupixent (dupilumab) (PG026, Ver. 14)
- Durysta (bimatoprost intracameral implant) (CG116, Ver. 3)
- Elevidys (delandistrogene moxeparvovec-rokl) (PG160)
- Erectile Dysfunction (CG037)
- Enteral and Oral Liquid Nutritional Supplements (CG011)
- Experimental or Investigational Services, Products, Drugs, and Biologicals (CG012, Ver. 12)
- Furoscix (furosemide) 8mg/1mL Solution for injection [On-Body Infusor] (PG132, Ver. 5)
- Glaucoma Surgery (CG034, Ver. 11)
- Growth Hormones (PG049)
- Hearing Aids (CG001)
- Hemgenix (etranacogene dezaparvovec) (CG075, Ver. 5)
- Home Births and Birth Centers (CG038)
- 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)
- Hyaluronate and Derivatives - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG094, Ver. 4)
- Hyperbaric Oxygen Therapy (CG014, Ver. 11)
- Hypoglossal Nerve Stimulation (CG065, Ver. 6)
- iDose TR (travoprost intracameral implant) (CG115)
- Ilaris (canakinumab) (PG185)
- Immune Globulin Weight-Based Dosing Criteria (PG256, Ver. 1)
- Infertility Injectable Agents (PG119)
- Insulin Delivery Systems and Continuous Glucose Monitoring (CG029, Ver. 15)
- Intraoperative Neuromonitoring (CG045, Ver. 9)
- Ilumya (tildrakizumab-asmn) (CG053, Ver. 8)
- Injectable Iron Supplements (PG196, Ver. 4)
- Injectable Iron Supplements - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG107, Ver. 3)
- Izervay (avancincaptad pegol) (PG168, Ver. 3)
- Kebilidi (eladocagene exuparvovec-tneq) (PG259, Ver. 1)
- Kisunla (donanemab-azbt) (PG238)
- Kymriah (tisagenlecleucel) (CG058)
- Lamzede (velmanase alfa-tycv) (PG146)
- Lantidra (donislecel-jujn) (PG167)
- Lemtrada (Alemtuzumab) (PG226, Ver. 2)
- Lenmeldy (atidarsagene autotemcel) (CG117, Ver. 3)
- Leqembi (lecanemab-irmb) (PG138)
- Long-Term Acute Care Hospital (LTACH) (CG062)
- Luxturna (voretigene neparvovec-rzyl) (CG060, Ver. 7)
- Lyfgenia (lovotibeglogene autotemcel) (CG114, Ver. 3)
- Medical Nutrition Therapy (Dietary Evaluation & Counseling) (CG010, Ver. 11)
- Mitoxantrone (Novantrone) (PG126, Ver. 4)
- Multiple Sclerosis Agents - Medical Benefit Preferred Physician-Administered Drug Exceptions Criteria (CG096, Ver. 4)
- NexoBrid (anacaulase-bcdb) (CG112)
- Niktimvo (axatilimab) (PG252, Ver. 2)
- Negative Pressure Wound Therapy and Negative Pressure Infusion Therapy (CG068)
- Noninvasive Positive Pressure Ventilation (CG003)
- Ocrelizumab (Ocrevus, Ocrevus Zunovo) (PG235, Ver. 4)
- Omisirge (omidubicel-onlv) (PG149)
- Optical Coherence Tomography (CG025)
- Outpatient Physical Therapy (PT) and Occupational Therapy (OT) (CG044, Ver. 9)
- Oxygen Therapy (CG005)
- 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)
- Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp] (PG245)
- Pedmark (sodium thiosulfate) (PG133)
- PiaSky (crovalimab-akkz) (PG262, Ver. 1)
- Pneumatic Compression Pumps (CG049)
- Prenatal Testing (CG043)
- Prescription Digital Therapeutics (PG142)
- Pressure-Reducing Support Surfaces (CG007)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitors (PG068)
- Qalsody (tofersen) (PG151, Ver. 4)
- Quantity Limit Exception Criteria (PG200, Ver. 3)
- Rebyota (fecal microbiota, live - jslm) (PG240)
- Rezzayo (rezafungin) (PG145)
- 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)
- Skilled Nursing Facility Care (CG042, Ver. 11)
- Skysona (elivaldogene autotemcel) (CG074)
- Soliris (eculizumab) (PG188, Ver. 2)
- Spevigo (spesolimab-sbzo) (CG071, Ver. 5)
- Spinal Orthoses (Back Braces) (CG051)
- Spravato (esketamine) (PG257, Ver. 1)
- Syfovre (pegcetacoplan injection) (PG150)
- Tevimbra (tislelizumab) (PG210, Ver. 2)
- Thyrogen (thyrotropin alfa) (PG140, Ver. 3)
- Total Hip Arthroplasty (CG070)
- Total Knee Arthroplasty (CG069)
- Total Shoulder Arthroplasty (Replacement) and Reverse Total Shoulder Arthroplasty (CG076)
- Transcranial Doppler (CG035, Ver. 11)
- Treatment and Removal of Benign Skin Lesions (CG015)
- Tremfya (guselkumab) (PG250)
- Tysabri (natalizumab) (PG195)
- Tzield (teplizumab-mzwv) (CG072, Ver. 4)
- Ultomiris (ravulizumab-cwvz) (PG189)
- Varicose Vein Treatment (CG004)
- Varubi (rolapitant) (PG178)
- Viscosupplementation for Osteoarthtiris (CG054, Ver. 9)
- Vyjuvek (beremagene geperpavec-svdt) (PG147, Ver. 3)
- Vyvgart (efgartigimod alfa-fcab) and Vyvgart Hytrulo (efgartigimod alfa-fcab) (PG191)
- Wearable Cardioverter Defibrillator Devices (CG019)
- Winrevair (sotatercept-csrk) (PG207, Ver. 2)
- Ycanth (cantharidin) (PG162, Ver. 3)
- Yescarta (axicabtagene ciloleucel) (CG063)
- 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