Medical Policies

Find the medical policy you need in the library below. If medical policy is not located, please refer to the list of specialized services to confirm if medical necessity review is needed.

For specialized services administered by independent companies on behalf of Capital Blue Cross:

You can also view the retired medical policies and out-of-area medical policies.

Behavioral Health Services:

As of January 1, 2025, Carelon Behavioral Health will no longer be Capital Blue Cross’ behavioral health manager for mental health and substance use disorder services.

We use industry standard clinical management criteria to determine medical necessity.

  • InterQual® Behavioral Health Criteria
  • American Society of Addiction Medicine (ASAM)

Behavioral health services may require preauthorization. Providers, please refer to the single source preauthorization list.

Specialty Injectables:

For more information about Specialty Injectable drugs, view our list of policies. Specialty Injectable drugs may require preauthorization. Providers, please refer to the single source preauthorization list. Some drugs may also have site of service requirements, please refer to the Drug Infusion Site of Service policy for guidance.

Specialty Injectable preauthorization forms are available for download in your secure provider library when electronic submission is unavailable.

Nonparticipating providers can also access forms and other commonly used resources when needed.

Medicare Information:

For additional Medicare coverage and policy information, please review the Medicare Medical Policy page.

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