CurrentBaylor Scott & White Health PlanPolicy 215

MEDICAL COVERAGE POLICY

Defines general medical necessity criteria, documentation requirements, prior authorization guidance, and continuation/renewal requirements for medications administered under the medical benefit when no more specific policy exists. Applies across lines of business with references to Medicare NCD/LCD and Texas Medicaid where relevant.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMEDICAL COVERAGE POLICY

Policy CodePolicy 215

Change TypeRevised and Added

Effective Date03/01/2026

Next Review Date02/26/2027

Key ActionWhen requesting coverage, follow applicable InterQual® criteria for prior authorization and submit documentation (diagnosis, labs/tests, medical records, and compendia or trial evidence for off-label use).

POLICY UPDATE CHANGES

Changed authorization renewal criteria to apply to continuation of therapy and adjusted authorization duration to maximum 12 months (02/26/2026).

Clarified step therapy applies to all preferred drugs and updated authorization duration to 6 months (06/09/2025 entry).

Removed Medicare NCD/LCD Interqual statement for clarity (08/11/2025 entry).

Policy clarifications and layout/format updates and movement of appendices to separate policies over multiple prior updates.

215Policy Number

12mMax Authorization

InterQualPrior Auth Ref

Texas MedicaidState Ref

Coverage Summary

This policy (Policy Number 215) covers medications administered under the medical benefit and is effective 03/01/2026. It defines medical necessity and coverage determination principles when no more specific medical policy exists and applies across lines of business (see plan EOC/SPD for benefit details). The coverage stance is covered_with_criteria; use is considered medically necessary only when the policy's criteria are met. Applicable InterQual® criteria must be used for medications that require prior authorization, and State/Federal mandates (for example, Medicare NCD/LCD and Texas Medicaid HB154) are referenced where relevant.

Key Policy Quick Facts

Policy Number215

Maximum Authorization Duration12 months

Prior Authorization ReferenceInterQual

State Mandate ReferenceTexas Medicaid (HB154)

Effective Date03/01/2026

Next Review02/26/2027

Medical-Necessity Criteria

Medical Necessity Criteria

The Plan considers use medically necessary when ALL of the following are met:

ALL of the following

The medication is prescribed by or in consultation with a specialist that has expertise in the applicable disease or condition.
The indicated diagnosis supplied in the request (including any applicable labs and/or tests) and medication usage is supported by documentation from the patient's medical records.
The drug is approved by the FDA for at least ONE indication.
ONE of
- The member meets the applicable criteria set in InterQual® if the medication requires prior authorization.

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Requirement

Prior authorization requirements vary by medication. When a medication requires prior authorization, applicable InterQual® criteria must be used. For Medicare and Medicaid plans, follow National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), or state mandates (e.g., TMHP/Texas Medicaid) as applicable. Refer to the member's plan EOC/SPD for plan-specific details.

Documentation Required

Documentation to Support Request

Provide the diagnosis and any relevant laboratory or test results, and submit supporting medical record documentation that demonstrates the medical need for the requested medication. For off-label indications, include supporting references from recognized compendia or the clinical trials that demonstrate safety and effectiveness.

Coding

CPT CodesCPT

No codes listed

HCPCS CodesHCPCS

No codes listed

ICD-10 codes (may apply)ICD-10

No codes listed

ICD-10 Not coveredICD-10Not Covered

No codes listed

Background

This general medical policy defines medical necessity and coverage determination principles for medications administered under the medical benefit when no more specific medical policy exists. It references the FDA product labeling for dosing and indications, recognized compendia (e.g., AHFS‑DI, NCCN, Micromedex, Clinical Pharmacology), clinical trial evidence requirements for off‑label uses, and InterQual® criteria for prior authorization. Oncology medications and select oncologic interventions are governed by a separate policy (BSWHP medical policy 219).

Off‑label or unlabeled drug use: Use of a drug approved by the FDA for other uses or in treatment regimens or patient populations not included in approved labeling.

Medicare Determinations

Determination Type (NCD/LCD)	Name	Number	Effective date
NCD	National Coverage Determination
LCD	Local Coverage Determination

Revision History

06/09/2025revised

Clarified step therapy applies to all preferred drugs and updated authorization duration to 6 months.

08/11/2025revised

Removed Medicare NCD/LCD Interqual statement for clarity.

02/26/2026revisedLatest

Changed authorization renewal criteria to apply to continuation of therapy and adjusted authorization duration to maximum 12 months.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyMEDICAL COVERAGE POLICY

Policy CodePolicy 215

Change TypeRevised and Added

Effective Date03/01/2026

Next Review Date02/26/2027

On This Page

ALL of the following

Use of the drug for the diagnosis is supported in a standard drug reference compendium (examples include American Hospital Formulary Service Drug Information (AFHS-DI) with supportive narrative text; National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium; Thomson Micromedex DrugDex with Strength of Recommendation Class IIb or better and Strength of Efficacy Class IIa or better; Clinical Pharmacology with supportive narrative text).
The safety and effectiveness of use for this indication has been demonstrated by at least 2 well-designed controlled clinical trials (Phase III or Phase IIb single center controlled) published in a nationally recognized peer-reviewed medical journal.
Clinical trials supporting off-label use must be supplied as part of the request.

ALL of the following

Following initial dosing, patient must have tried, and failed, standard FDA-approved dosing and frequency as documented in the patient's medical records in order to qualify for the use of increased doses per the product labeling (dose increases or more frequent dosing).
Medications given beyond FDA labeling maximum dosages based on patient body size or a set maximal dosage independent of patient body size, not supported by package labeling, pharmacy compendia, or peer-reviewed published clinical evidence, are unproven and may not be medically necessary.

For medications with a non-preferred status, member must have failure of an adequate trial of or clinically significant intolerance or contraindication to ALL preferred drugs in the same class that can also be used for the requested indication.

Refer to BSWHP medical policies 306 Step Therapy - Commercial and 307 Step Therapy - Medicare.

Continuation of therapy requires ALL of

Continued use of the drug and dosing is consistent with all criteria above.
Improvement, stabilization of disease, or a reduction in normal decline seen in the applicable population.
Manageable or no side effects.

Approval Duration

Approval duration is the shortest of the following:

ANY of the following

Clinically appropriate duration.
12 months.
Requested duration.

For oncology medications and other select oncologic interventions, refer to BSWHP medical policy 219 Cancer Chemotherapy/Therapy Guidelines.

Step Therapy

Step Therapy for Non-Preferred Drugs

For non-preferred medications, document that the member has had an adequate trial with, and experienced failure of, or a clinically significant intolerance or contraindication to ALL preferred drugs in the same class that can be used for the requested indication. See BSWHP Step Therapy policies (policies 306 and 307) for specifics.

Documentation Required

Continuation/Renewal Documentation

For continuation or renewal requests, submit clinical documentation showing continued benefit such as ongoing improvement or stabilization (or reduction in expected decline), that continued use and dosing meet the policy criteria, and that side effects are manageable or absent.

Billing Rule

Applicability Across Lines of Business

This policy applies to all lines of business unless a more specific medical policy exists or federal/state mandates supersede. Benefits are ultimately determined by the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD); consult those documents for plan-specific coverage and any superseding requirements.