• When it is requested or planned (prospective or pre-service review).
• During the course of care (inpatient or outpatient ongoing care review).
• After services have been delivered (retrospective or post-service review).

With so many variables, it may help to get a clear picture of what to expect and how the process works.

Timing is important

We are committed to deciding cases quickly and professionally. Here are several time frames
you can expect:

Urgent pre-service review requests

An urgent pre-service review request is a request for pre-service review that in the view of the treating provider or any physician with knowledge of the member’s medical or behavioral condition could without such care and treatment subject the member to adverse health consequences, pose an imminent and serious threat to the member’s life or health or their ability to regain maximum function, or seriously jeopardize the life, health or safety of the member or others due to the member’s psychological state.

Notification of delay in review determination

If we do not have the information we need to make our decision, we will try to get it from the physician or other healthcare provider who is requesting the service, medical procedure or equipment. If a delay is anticipated because the information is not readily available, we will notify the member as well as the requesting physician or other healthcare provider in writing. Delay letters include a description of the information we need to make a decision and also specify when the decision can be expected once the information is received. If we do not receive the necessary information, we will send a final letter explaining that we are unable to approve access to benefits due to lack of the information requested.

We use professional, qualified reviewers

Experienced clinicians review requests for services using medical criteria, established guidelines and applicable medical policies. Requests for covered benefits meeting those standards are certified as medically necessary.

Only a peer clinical reviewer may determine that a service is not medically necessary

Peer clinical reviewers (PCRs) are California licensed healthcare professionals qualified and clinically competent to evaluate the specific clinical aspects of the request and/or treatment under review. PCRs are licensed in California in the same license category as the requesting physician or other healthcare provider. If you are the treating practitioner directly involved in the member’s care/treatment plan and need to discuss a medical necessity review decision, an Anthem Blue Cross (Anthem) medical director or peer clinical reviewer is available at
800-794-0838. If the PCR is unable to approve a service, the requesting physician, another healthcare provider or the member has the right to request an appeal.

Decisions not to approve are in writing

Written notice is sent to the member and the requesting physician or other healthcare provider within two business days of the decision. This written notice includes:

• A clear and concise explanation of the reason for the decision.
• The name of the criteria and/or guidelines used to make the decision.
• The name and phone number of the peer clinical reviewer who made the decision, for
  peer-to-peer discussion.
• Instructions for how to appeal a decision.
• Specific provisions of the contract that excludes coverage if the denial is based upon benefit coverage.

Access to criteria

Anthem Medical Policy and Clinical Utilization Management Guidelines for specific services are available to members, member representatives, healthcare providers and the public. Members may call the number on the back of their ID card for a copy of the guidelines used to determine their case. Anthem Medical Policy and Clinical Utilization Management Guidelines are also available at www.anthem.com/ca. Providers can access utilization management criteria by selecting the For Providers drop down at the top of the screen. Under Provider Resources, select Policies, Guidelines & Manuals. Scroll down and select View Medical Policies & Clinical UM Guidelines; or call 800-794-0838 to request that a paper copy be sent to you. The requested criteria is provided free of charge.     

A determination of medical necessity does not guarantee payment or coverage

The determination that services are medically necessary is based on the clinical information provided. Payment is based on the terms of a member’s coverage at the time of service. These terms include certain exclusions, limitations and other conditions, as outlined in the member’s evidence of coverage or benefit booklet. Payment of benefits could be limited for a number of reasons, for example:

• The information submitted with the claim differs from that given at time of review.
• The service performed is excluded from coverage.
• The member is not eligible for coverage when the service is actually provided.

Decisions about coverage of service

Our utilization management decisions are based on the appropriateness of care and service needed, as well as the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing denials of coverage, service or care. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for utilization management decision makers to encourage decisions resulting in under-utilization. 

We are available for questions

If you need to request precertification, need information about our utilization management process, or have questions or issues, call our toll-free number at 800-274-7767. Our associates are available Monday through Friday (except holidays), 8 a.m. to 5 p.m. Pacific time. If you call after hours or do not reach someone during business hours, you may leave a confidential voice mail message. Please leave your name and phone number; we will return your call no later than the next business day during the hours listed above, unless other arrangements are made. Calls received after midnight will be returned the same business day. Our utilization management associates identify themselves to all callers by first name, title and our company name when making or returning calls.

Language assistance

For those who request language services, Anthem provides service in the requested language through bilingual staff or an interpreter, to help members with their utilization management issues. Language assistance is provided to members free of charge. Oral interpretation is available at all points of member contact regarding utilization management issues.

TDD/TTY services

TDD (telecommunications device for the deaf) or TTY (telephone typewriter, or teletypewriter) is an electronic device for text communication via a telephone line, used when one or more parties have hearing or speech difficulties. If you have a hearing or speech loss, call 711 to use the National Relay Service or the number below for the California Relay Service. A special operator will contact Anthem to help with member needs.

For English TTY/English voice, call 800-855-7100.

The law does not require a health plan to cover an experimental or investigational treatment. Abortion is defined as any medical treatment intended to induce the termination of a pregnancy except for the purpose of producing a live birth.

The law provides that for a high deductible health plan, the cost-sharing limits described in the law shall apply once an enrollee’s deductible has been satisfied for the benefit year.

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If updates are needed, you can use our online Provider Maintenance Form. Once you submit the form, you will receive an email acknowledging receipt of your request. Visit the
Provider Maintenance Form webpage for complete instructions.

Online update options include:

• Add/change an address location.
• Name change.
• Tax ID changes.
• Provider leaving a group or a single location.
• Phone/fax number changes.
• Closing a practice location.

Note that some updates may require additional documentation.

All guidelines are reviewed annually, and updated as needed. The current guidelines are available on our website at anthem.com/ca > For Providers > Select Policies, Guidelines & Manuals under Provider Resources > scroll down and select Clinical Practice Guidelines or Preventive Health Guidelines.

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It can be found on our website under the FAQ question about Laws and Rights that Protect You. To access, go to https://www.anthem.com/ca and select For Providers. From there, select Policies, Guidelines & Manuals under Provider Resources. Select your state, and scroll down to Member Rights and Responsibilities under More Resources. Choose the Read about member rights link. Practitioners may access the FEP member website at www.fepblue.org/memberrights to view the FEPDO Members’ Rights and Responsibilities statement.

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The annual after-hours access studies performed by our vendor, North American Testing Organization* based in California, assesses adequate phone messaging for our members with perceived emergency or urgent situations after office hours. Unfortunately, Anthem Blue Cross (Anthem) still falls short of the expectation of having a live person or a directive in place for after-hours calls.

Well, the members are experiencing this lack of ability to reach instructions and have voiced their opinions in the member experience survey fielded annually for commercial and marketplace exchange via a behavioral health specific survey. An average of 29% of members have a need to contact their behavioral health practitioner after regular hours for urgent care. They are recalling, in the last 12 months, if they were able to reach the office for instructions, get a consultation they needed or get a timely call back?

This chart represents the office level accessibility when contacted by the survey vendor compared to the member satisfaction survey results of the member’s success getting their urgent needs meet after hours. As shown, the office level results are significantly below the expected 90% access to members with urgent symptoms.

Ironically, members express getting advice as soon as needed more often than the office assessment captures. Although a number of members sometimes, or never, reached the practitioner’s office for urgent instructions.

To help both your patients’ and Anthem’s ability to reach your practice, we ask that you verify or update your office information using the online Provider Maintenance Form and that you also review your after-hours messaging and connectivity for patients’ urgent accessibility.

1. Have accessibility 24/7/365. Arrange to have your phone calls forwarded to a service or hospital, or have the appropriate messaging for the caller.
2. Be sure to turn on a messaging mechanism when you leave the office.
3. Be sure you are using the acceptable messaging for compliance with your contract.

Per the Provider Manual, have your messaging or answering service include appropriate instructions, specifically:

Emergency situations

Compliant response for an emergency instructs the caller/patient to hang up and call 911 or go to the Emergency Room (ER) or live person connects the caller directly to the practitioner.

Emergent/Urgent situations

Compliant responses for urgent needs after hours:

• Live person or via a service, advises their practitioner or on call practitioner is available and connects.
• Live person or recording directs or directly connects caller/patient to Urgent Care, 24-hour crisis services, 911 or ER.
  • May also, but not instead of directing, suggest caller/patient may contact their BH care practitioner (via cell phone, pager, text, email, voicemail, etc.) or request a call back for further urgent instructions.
• If a caller chooses to use a method to request a call back, a live person or recording must give the length of time for a return call.
• Mechanism connects the caller to their practitioner or the practitioner on call.  (Must directly connect.)
• A live person or recording must express if there are prior arrangements with patients for after hour needs, to be compliant.

Non-compliant responses for urgent needs after hours:

• No provision for after hour accessibility.
• Live person or recording only directs the caller/patient to a mechanism for contacting their practitioner (via cell phone, pager, text, email, voicemail, etc.) or to get a call back for urgent questions or instructions.
  These scenarios are non-compliant because there is no direct connection to their practitioner, thus not ensuring a timely callback. This prompt can be used in addition to, but not in place of instructions.

Coordination of care is especially important for patients with high utilization of general medical services, and those referred to a behavioral health specialist by another healthcare practitioner. Anthem urges all its practitioners to obtain the appropriate permission from these patients to coordinate care between behavioral health and other healthcare practitioners at the time treatment begins.

We expect all healthcare practitioners to:

• Discuss with the patient the importance of communicating with other treating practitioners.
• Obtain a signed release from the patient and file a copy in the medical record.
• Document in the medical record if the patient refuses to sign a release.
• Document in the medical record if you request a consultation.
• If you make a referral, transmit necessary information, and if you are furnishing a referral, report appropriate information back to the referring practitioner.
• Document evidence of clinical feedback (for example, consultation report) that includes, but is not limited to:
  • Diagnosis.
  • Treatment plan.
  • Referrals.
  • Psychopharmacological medication (as applicable).

In an effort to facilitate coordination of care, Anthem has several tools available on our provider website for behavioral health and other medical practitioners including:

• Coordination of Care Form.
• Coordination of Care Letter Template - Behavioral Health.
• Coordination of Care Letter Template - Medical.

The following behavioral health forms, brochures, and screening tools for substance use and attention-deficit/hyperactivity disorder (ADHD) are also available on our provider website:

• Alcohol Use Assessment
• Antidepressant medication management.
• Edinburgh Postnatal Depression Scale.
• Opioid Use Assessment brochure.
• Substance Brief Intervention/Referral Tool (SBIRT).
• Vanderbilt ADHD Diagnostic Parent Rating Scale.

Anthem Blue Cross is available to offer assistance in these difficult moments with our Case Management Program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals that are there to support members, families, primary care physicians and caregivers. The case management process utilizes experience and expertise of the care coordination team whose goal is to educate and empower our members to increase self-management skills, understand their illness, and learn about care choices in order to access quality, efficient health care.

Members or caregivers can refer themselves or family members by calling the number located in the grid below. They will be transferred to a team member based on the immediate need. Physicians can also refer by contacting us telephonically or through electronic means. No issue is too big or too small. We can help with transitions across level of care so that patients and caregivers are better prepared and informed about healthcare decisions and goals.

How do you contact us?

As you know, Anthem Blue Cross (Anthem) monitors member access to a provider’s care through several mechanisms, including provider and member surveys. These surveys are conducted by Anthem and external entities, such as Sutherland Healthcare Solutions, North American Testing Organization, and the CAHPS^® program.  

Surveys give insight:

• In surveying compliance with After Hours standards, participating providers’ offices are called outside of normal business hours to determine if callers are given appropriate emergency instructions and have a mechanism to reach a provider after regular hours for urgent situations.
• In surveying compliance with Appointment Availability standards, participating providers’ offices are called within normal business hours and are asked when the next available appointment for urgent and non-urgent care would be.
• Members are also surveyed via mail. The surveys, in addition to monitoring member complaints, help us to identify whether access to care is available to our members after or before normal business hours.

 The key to our 2022 success is…you!

If you have already taken steps to comply with the standards - thank you. This year’s surveys are now under way, and with your continued support and commitment, we can achieve the best results possible for 2022.

Take a minute to review the 2021 survey results in the table below. We hope sharing them with you provides a better understanding of how you can help improve 2022 results.

Provider After Hours results - 2021 survey

Provider Appointment Availability Survey (PAAS) results - 2021 Survey

 You make a difference:

• Review the Commercial Access Standards under the Legal and Administrative Requirements section in your Anthem Blue Cross California Facility and Professional Provider Manual. Make sure your practice policy and procedures comply with the standards.
• Ensure your after-hours office staff, answering service, or answering machine message specifically informs callers when their urgent (nonemergent) calls will be returned.
• Ensure your after-hours office staff, answering service, or answering machine message directs callers to dial 911 or go to the nearest emergency room if they are experiencing an emergency.
• Ensure that your office staff are aware of and able to comply with the appointment availability standards when setting appointments for our members.

If your office was surveyed in 2021 and was found noncompliant with these standards, a letter with recommended compliance measures was sent to an active mailing address on file for you.

If you have questions, email your Provider Experience representative for assistance from the Contact Us page. Select Provider Experience team to open the email form and make sure to enter the words, 2021 Survey After Hours and PAAS Results in the subject field.  Visit us online to view other contact options.

This communication applies to the Commercial and Medicare Advantage programs from Anthem Blue Cross (Anthem) in California.

For our Commercial and Medicare Advantage plans

Our pharmacy benefit management partner IngenioRx will join the Carelon family of companies and change its name to CarelonRx on January 1, 2023.

This change will not affect the ways in which CarelonRx will do business with care providers and there will be no impact or changes to the prior authorization process, how claims are processed, or level of support.

If your patients are having their medications filled through IngenioRx’s home delivery and specialty pharmacies, please take note of the following information:

• IngenioRx Home Delivery Pharmacy will become CarelonRx Mail.
• IngenioRx Specialty Pharmacy will become CarelonRx Specialty Pharmacy.

These are name changes only and will not impact patients’ benefits, coverage, or how their medications are filled. Your patients will not need new prescriptions for medicine they currently take.

When e-prescribing orders to the mail and specialty pharmacies:

• Prescribers will need to choose CarelonRx Mail or CarelonRx Specialty Pharmacy, not IngenioRx, if searching by name.
• if searching by NPI (National Provider Identifier), the NPI will not change.

In addition to the mail and specialty pharmacies, your patients can continue to have their prescriptions filled at any in-network retail pharmacy.

* IngenioRx, Inc. is an independent company providing pharmacy benefit management services on behalf of Anthem Blue Cross.
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Anthem strives to ensure our providers understand documentation compliance, and we are committed to educating our providers in hopes of eliminating errors in documentation practices. It is a best practice and industry standard that physicians sign and date laboratory orders or requisitions.

Although the provider signature is not required on laboratory requisitions, if signed and dated, the requisition will serve as acceptable documentation of a physician order for the testing and so is it strongly encouraged. In the absence of a signed requisition, documentation of your intent to order each laboratory test must be included in the patient’s medical record and available to Anthem upon request. Documentation must accurately describe the individual tests ordered; it is not sufficient to state “labs ordered.”

Anthem will consider laboratory order or requisition requirements met with one of the following:

• A signed order or requisition listing the specific test(s)
• An unsigned order or requisition listing the specific test(s), and an authenticated medical record supporting the physician’s intent to order the test(s)
• An authenticated medical record (for example, office notes or progress notes) supporting the physician’s intent to order the specific test(s)

Attestation statements are not acceptable for unsigned physician order or requisitions. Signature stamps are not acceptable.

References:

• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/LabServices-ICN909221-Text-Only.pdf
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Signature_Requirements_Fact_Sheet_ICN905364.pdf
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/medicare-provider-compliance-tips/medicare-provider-compliance-tips.html#BloodCount
• Title 42 CFR §410.32
• Documentation Standards for Episodes of Care – Professional Administrative

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In other states, a company may carry the Blue Cross and Blue Shield name together, as a single entity. In California, there are two separate and independent companies - one is Anthem Blue Cross and the other is Blue Shield of California. 

• If you contract with both plans in California, you may file an out-of-area Blue Plan member’s claim with either plan.
• If you contract with one plan but not the other, file all out-of-area claims with your contracted plan. 

Use the Anthem Blue Cross payer ID number that was assigned to you, not the Blue Shield of California payer ID number. If you submit an Anthem Blue Cross member claim with the Blue Shield of California payer ID number instead of the Anthem Blue Cross payer ID number, the claim will process as out-of-network.

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• Make a copy of the front and back of the member’s ID card.
• Look for the three-character prefix on the member’s ID number.
• Call BlueCard Eligibility at 800-676-BLUE (2583) to verify the patient’s membership and coverage or submit an electronic HIPAA 270 transaction (eligibility) to Anthem.
• Submit the claim to Anthem. Always include the patient’s complete ID number, including the three-character prefix.

For claims inquiries, contact Anthem.

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Also, you have access to online supplemental education materials (SEM), with SEM#10 - BlueCard (Out-of-Area) available via the Anthem Blue Cross Provider Education and Training webpage, which provides helpful tips to improve your claim experience, facts about ID cards, and much more.

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Refer to the Anthem Blue Cross — California Facility and Professional Provider Manual for timeframes and information about reporting your practice status and other related information about your practice.

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We encourage you to use the online Provider Maintenance Form to notify us about your telehealth services and we will add a telehealth indicator to your online provider directory profile.

Visit https://www.anthem.com/ca to locate the Provider Maintenance Form.

We previously communicated that AIM Specialty Health_® (AIM),* a separate company, would expand the AIM Musculoskeletal program to perform medical necessity review of the requested site of service for certain joint and interventional pain procedures beginning September 1, 2022. The expansion was delayed and will now be effective January 1, 2023, for Anthem Blue Cross’s (Anthem) self-funded (administrative services only) group members, as further outlined below.

AIM will continue to manage the AIM Musculoskeletal program and level of care review. The AIM level of care guideline for musculoskeletal surgery and procedures is used for the level of care review. Prior authorization will now also be required for the clinical appropriateness of the site in which the procedure is performed (site of care). AIM will use the following Anthem Clinical Utilization Management Guideline: CG-SURG-52: Site of Care: Hospital-Based Ambulatory Surgical Procedures and Endoscopic Services. The Clinical Criteria to be used for these reviews can be found at https://www.anthem.com/ca/provider/policies/. Please note, this does not apply to procedures performed on an emergent basis.

A subset of the AIM Musculoskeletal program codes will be reviewed for site of care. A complete list of CPT^® codes requiring prior authorization for the AIM Musculoskeletal site of care program is available on the AIM Musculoskeletal microsite. To determine if prior authorization is needed for an Anthem member on or after January 1, 2023, providers can contact the Provider Services phone number on the back of the member’s ID card for benefit information. Providers will be informed whether the AIM Musculoskeletal program applies. AIM will also have a file upload from the health plan of the in-scope membership and will not provide prior authorization for members who are out of scope. If providers use the Interactive Care Reviewer (ICR) tool on Availity* to pre-certify an outpatient musculoskeletal, ICR will produce a message referring the provider to AIM. (Note: ICR cannot accept prior authorization requests for services administered by AIM.)

Members included in the new program

This program will be available to a small volume of self-funded (administrative services only) groups that currently participate in the AIM Musculoskeletal program and have added the AIM Musculoskeletal site of care program to their members’ benefit package as of January 1, 2023. Program readiness was evaluated, and it was determined that we are not ready to launch for the fully insured membership. It will also expand to fully insured members currently participating in the AIM Musculoskeletal program at a future date.

Pre-service review requirements

For surgeries that are scheduled to begin on or after January 1, 2023, all providers must contact AIM to obtain prior authorization review. The following groups are excluded: Medicare Advantage, Medicaid, Medicare, Medicare supplement, MA GRS, and the Federal Employee Program^® (FEP^®).

For services provided on or after January 1, 2023, ordering and servicing providers may begin contacting AIM on January 1 for review. Providers may submit prior authorization requests to AIM in one of several ways:

• Access AIM’s ProviderPortal_SM directly at https://aimspecialtyhealth.com/providerportal. Online access is available 24/7 to process orders in real-time, and this is the fastest and most convenient way to request authorization.
• Access AIM via Availity at www.availity.com.
• Call the AIM Contact Center toll-free number at 877-430-2288, Monday through
  Friday, 8 a.m. to 6 p.m. ET.

Initiating a request on AIM’s ProviderPortal_SM and entering all the requested clinical questions will allow you to receive an immediate determination. If the request is approved, you will receive the order ID, the number of visits, and valid time frame. The AIM Musculoskeletal program microsite on the AIM provider website helps you learn more, and you can access helpful information and tools such as order entry checklists.

AIM Musculoskeletal training webinars                                                                    

Anthem invites you to take advantage of a free informational webinar that will introduce you to the program and the robust capabilities of the AIM ProviderPortal_SM.  Go to the AIM Musculoskeletal microsite to register for an upcoming webinar. If you have previously registered for other services managed by AIM, there is no need to register again.

* AIM Specialty Health is an independent company providing some utilization review services on behalf of Anthem Blue Cross. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.
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The Pregnancy Notification Form is available on the Anthem Blue Cross provider website at https://providers.anthem.com/ca > Resources > Forms under the Pregnancy and Maternal Child Services section for easy access and will replace any existing pregnancy notification form you are currently using.

You may also download the form here:

https://providers.anthem.com/docs/gpp/california-provider/CA_PregnancyNotificationFormCLUpdate.pdf?v=202010130128

If you have questions, please contact Provider Services at 800-407-4627 (outside L.A. County), 888-285-7801 (inside L.A. County), or your OB Practice Consultant.

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Who can use this new tool?

Digital provider enrollment is currently only available for professional practitioners. 

Note: Facilities and providers who submit rosters or have delegated agreements will continue to use the existing enrollment process in place.

What features does the tool provide?

• Apply to add new practitioners to an already existing group
• Apply and request a contract to enroll a new group of practitioners
• Monitor submitted applications statuses real-time with a digital dashboard

How the online enrollment application works

The system pulls in all your professional and practice details from Council for Affordable Quality Healthcare (CAQH) ProView to populate the information Anthem needs to complete the enrollment process - including credentialing, claims, and directory administration. Please ensure your provider information on CAQH is updated and in complete or re-attested status.

The online enrollment application will guide you through the process, and a dashboard will display real-time application statuses. You’ll know where each provider is in the process without having to call or email for a status. 

Accessing the provider enrollment application

Log onto https://availity.com and select Payer Spaces > Anthem > Applications > Provider Enrollment to begin the enrollment process.

Before you begin

If your organization is not currently registered for Availity, the person in your organization designated as the Availity administrator should go to https://availity.com and select Register.

For organizations already using Availity, your administrator(s) will automatically be granted access to the provider enrollment tool.

Staff using the provider enrollment tool need to be granted the user role Provider Enrollment by an administrator. To find yours, go to My Account Dashboard > My Account > Organization(s) > Administrator Information.

Need assistance with registering for Availity?

* Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross.
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• Medical Policies and Clinical Utilization Management Guidelines update

• Prior authorization updates for medications billed under the medical benefit (Releuko, Vabysmo)

These nationwide impacts have led to many members unable to use the benefit to its fullest capacity. Therefore, effective January 1, 2023, the personal home helper benefit will no longer be offered within any of Anthem Blue Cross’s (Anthem’s) Medicare individual plans. Members have been notified via their Annual Notice of Change. Improving the life of our members is Anthem’s focus and, while this change is difficult, Anthem will make best efforts to identify other resources for members or benefits to enhance their quality of life.

• AIM Specialty Health Cardiology Clinical Appropriateness Guidelines CPT Code List update

• Medical Policies and Clinical Utilization Management Guidelines update

(Medicare-Medicaid Plan) will change to a Dual-Eligible Special Needs Plan (D-SNP) named Anthem MediBlue Full Dual Advantage (HMO D-SNP). The new plan coordinates care for those with both Medicare and Medicaid.

No action is needed by care providers or members already enrolled in Anthem Blue Cross Cal MediConnect. Members will receive a new ID card in the mail. 

For more information:

• Members can visit https://mss.anthem.com/california-mmp/home.html for specific details on the transition.
• Medicare providers can read more on this transition on the California Department of Health Care Services website.

• Medical Policies and Clinical Utilization Management Guidelines update

• Medical drug benefit Clinical Criteria updates