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.

Specialty Injectables:

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. Related medical policies are listed below.

Medicare Information:

Capital Blue Cross defers to Centers for Medicare and Medicaid Services (CMS) guidelines for coverage positions for our Medicare Advantage (HMO and PPO) lines of business. CMS guidance takes precedence; where no Medicare guidelines exist, Capital Blue Cross will defer to its existing commercial medical policy. Commercial Medical Injectable Policies do not apply.

For additional Medicare coverage and payment information, please review the Medicare Coverage Guidance information page.

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