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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty Drugssimplyhealthcare injectable drug criteria Posted |…
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    CurrentsimplyhealthcarePolicy SFLPEC-NL-0004-18

    Clinical criteria web page for injectable, infused, or implanted medical-benefit drugs

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    Announces a new Clinical Criteria website where providers can view clinical criteria documents for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit; initially posted for familiarization and not yet used for clinical reviews. Affects providers who order or authorize medical-benefit injectable, infused, or implanted drugs.

    Policy Summary
    Payersimplyhealthcare
    PolicyClinical criteria web page for injectable, infused, or implanted medical-benefit drugs
    Policy CodePolicy SFLPEC-NL-0004-18
    Change TypeInformational — website posting for provider familiarization
    Effective DateMar 1, 2019
    Next Review Date
    Key ActionProviders may view the clinical criteria documents on the Clinical Criteria website beginning March 1, 2019 for familiarization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    Mar 1, 2019website availability
    mid-2019oncology posting timeframe
    0documents used for clinical reviews

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Clinical Criteria Website & Posting

    Website posting (informational)

    Informational — website hosting clinical criteria documents for injectable, infused, or implanted drugs; not yet operative for coverage determinations.

    Familiarization posting: Clinical criteria documents for injectable, infused, or implanted prescription drugs will be posted to the Clinical Criteria website beginning March 1, 2019 for providers to review and familiarize themselves with the new location and formatting.

    These documents are not yet being used for clinical reviews or utilization decisions; providers will be notified prior to implementation.

    Scope note: The website will provide clinical criteria documents for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit.

    Injectable oncology drug clinical criteria will not be posted until mid-2019.

    Prior authorization and operational guidance: Until the clinical criteria documents are implemented, there is no change to the current prior authorization process; providers should continue to access clinical criteria through the standard process.

    Providers may view the documents beginning March 1, 2019 for familiarization only; clinical reviews will not be based on these posted documents until after formal implementation and notice.

    Injectable oncology drug clinical criteria will not be posted until mid-2019. The Clinical Criteria website will initially host non-oncology injectable, infused, or implanted drug criteria beginning March 1, 2019, with oncology-specific injectable criteria added at the later timeframe noted above.

    These clinical criteria documents are provided for provider familiarization and are not yet being used for clinical reviews. This notice does not include any new not-medically-necessary rules; no NMN policies are being implemented as part of this posting.

    What Providers Must Do / Expect

    Prior Authorization

    Prior authorization process unchanged for now

    No change to the current prior authorization process. Until clinical criteria documents are implemented for use in clinical review, providers should continue to access clinical criteria for medical-benefit medications through the standard prior authorization workflows.

    Step Therapy

    No step therapy changes

    There are no step therapy requirements or changes specified in this announcement; nothing in this notice adds or alters step therapy requirements at this time.

    Documentation Required

    Provider familiarization access beginning March 1, 2019

    Providers may view the clinical criteria documents on the Clinical Criteria website beginning March 1, 2019 for familiarization; these documents are not yet being used for clinical reviews.

    • Website available for provider review starting March 1, 2019
    • Materials posted are for familiarization only and do not currently affect clinical review processes
    Denial Risk

    No immediate coverage/denial effects

    Clinical criteria documents posted on the new site are not yet used for clinical reviews and therefore do not trigger denials or immediate coverage effects; providers will be notified before the criteria are implemented for review or utilization decisions.

    • Injectable oncology clinical criteria will be posted later (mid-2019) and are not currently in use
    • Until implementation, providers must continue using the standard process for clinical criteria access

    Background & Scope

    Beginning March 1, 2019, Simply Healthcare Plans will host clinical criteria documents on a new Clinical Criteria website for injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. These documents will be available for providers to review and familiarize themselves with the new location and formatting but will not be used for clinical review or utilization decisions until providers are notified prior to implementation.

    Key Definitions

    Clinical criteria documents (definition)
    DefinitionProvider-facing documents that describe the clinical requirements for coverage of injectable, infused, or implanted prescription drugs and therapies under the medical benefit.
    PurposePosted for provider familiarization with the new location and formatting; not yet used for clinical review or utilization decisions.
    Availability date for familiarizationProviders may view the Clinical Criteria website beginning March 1, 2019.
    Implementation statusThese clinical criteria documents are not yet being used for clinical reviews; providers will be notified prior to implementation.
    ExceptionsInjectable oncology drug clinical criteria will not be posted to the site until mid-2019.
    Provider action until implementationUntil implementation, continue to access clinical criteria for medical-benefit medications through the standard process.
    Policy Summary
    Payersimplyhealthcare
    PolicyClinical criteria web page for injectable, infused, or implanted medical-benefit drugs
    Policy CodePolicy SFLPEC-NL-0004-18
    Change TypeInformational — website posting for provider familiarization
    Effective DateMar 1, 2019
    Next Review Date
    Key ActionProviders may view the clinical criteria documents on the Clinical Criteria website beginning March 1, 2019 for familiarization.
    SourceLink
    On This Page
    Clinical Criteria Website & PostingWhat Providers Must Do / ExpectBackground & ScopeKey Definitions