The Medicare Advantage (MA) Plan must follow all traditional Medicare NCDs and LCDs applicable to the MA Plan’s service area per 42 CFR § 422.101. When coverage criteria are not fully established in traditional Medicare statutes, regulations, NCDs or LCDs (applicable to the MA Plan’s service area), internal coverage criteria can be developed. Internal coverage criteria may be similar or the same as criteria found in LCDs that are applicable outside the MA Plan’s service area, as long as, the criteria are based on current evidence in widely used treatment guidelines or clinical literature and is made publicly available.
The Blue Advantage medical policies below offer clinical guidelines for healthcare providers. These policies are a summary of evidence, list of resources and an explanation of the rationale that supports the adoption of the coverage criteria and are used unless Federal law takes precedence over the policy. Blue Advantage partners with Carelon Medical Benefit Management to review certain services for our Medicare Advantage population. The policies utilized by Carelon for those reviews can be accessed here: www.guidelines.carelonmedicalbenefitsmanagement.com.
In addition, Blue Advantage uses InterQual criteria, which can be accessed (by providers and members) through the InterQual® Transparency Tool. Registration is required to access the InterQual tool.
Some medical drug policies may include a step therapy component as part of the criteria to determine medical necessity. The list of drugs which have this additional component can be viewed here: Medicare Part B (Medical Drug) Step Therapy List.
Please verify member benefits, limitations and exclusions of coverage before services are rendered.
To find a Medicare medical policy, click here.
Future Effective Date
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