Provider manuals and guides
We are committed to supporting you in providing quality care and services to Healthy Blue members. Here you will find information for assessing coverage options, guidelines for clinical utilization management (UM), practice policies and support for delivering benefits to our members.
Provider Manual
Healthy Blue’s provider manual provides key administrative information including the quality improvement program, the UM program, quality standards for participation, claims appeals, and reimbursement and administration policies.
View or download the provider manual.
View or download the Quick Reference Guide.
Medical Policies and Clinical UM Guidelines
Medical Policies address the medical necessity of new services or procedures and new applications of existing services or procedures. Clinical UM Guidelines focus on detailed selection criteria, lengths of stay goals, and location for generally accepted technologies or services.
Pharmacy Criteria
- Antifungal Agents
- Behavioral Health Clinical Edits Criteria - Adult
- Behavioral Health Clinical Edits Criteria - Pediatric
- Celebrex - Celecoxib
- Cialis
- Crinone
- Crohns Disease
- Cystic Fibrosis - Kalydeco, Orkambi, Symdeko
- Dupixent for Asthma
- Emend
- Emflaza
- Entresto
- Epinephrine Auto-Injections
- Exondys 51
- Fasenra
- Gocovri and Osmolex ER
- Growth Hormones
- Hematinics - Procrit, Epogen, Aranesp
- Hepatitis C Virus Medications
- Hetlioz
- Juxtapid and Kynamro
- Lupus Medications
- Migraine Therapy - Calcitonin Gene-Related
- Monoclonal Antibodies
- Movement Disorders
- Neuromuscular Blocking Agents
- Opioid Analgesics
- Opioid Dependence Therapy Agents
- PCSK9 Inhibitors
- Plaque Psoriasis
- Provigil - Nuvigil
- Sedative Hypnotics
- Synagis
- Systemic Immunomodulators
- Topical Antihistamines
- Topical Anti-Inflammatories
- Topical Local Anesthetics - Lidoderm
- Triptans
- Xenazine and Tetrabenazine