Welcome to the Clinical Criteria

Clinical Criteria Overview

This page provides the clinical criteria documents for all injectable, infused, or implanted prescription drugs and therapies covered under the medical benefit. The effective dates for using these documents for clinical reviews are communicated through the provider notification process.

The Clinical Criteria information is alphabetized in the table below. You can also perform a search by entering any of the information from the table into the Search box.

Please note: Clinical criteria for orals or self-injectables can be found in our searchable drug lists within the Drug List Search tab. Enter the name of the drug you're looking for, select the drug and dose you want, and click on Clinical Criteria under the Notes & Restrictions section.

For commercial plan members using our Medical Specialty Precertification Drug List, precertification is required for certain medical specialty drugs. Choose your plan below for a complete list of medical specialty drugs requiring clinical review by CarelonRx.

Medical Specialty Precertification Drug List | Medical Specialty Precertification Drug List (PDF)

With our Site of Care program, certain specialty drugs when covered under the medical benefit require additional clinical review under CarelonRx clinical utilization management guidelines. Request for use of outpatient infusion or injectable therapy service in the hospital outpatient department or hospital outpatient clinic will be reviewed for medical necessity. Choose your plan for a complete list of drugs requiring site of care review.

Site of Care Drug List | Site of Care Drug List (PDF)

Development of clinical criteria

All clinical criteria are developed to help guide clinically appropriate use of drugs and therapies and are reviewed and approved by the CarelonRx^® Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an independent, external committee including practicing physicians, pharmacists, and clinicians from leading academic medical centers and clinical practices with evidence-based medicine. All major clinical specialties are represented.

If you have questions or feedback, please contact druglist@carelon.com.