Quality Measures Help Track Members’ Heart Health

Heart disease and stroke are among the leading causes of death in the U.S. We track measures related to our members’ blood pressure control and statin therapy. Learn steps to help identify and close care gaps.

Call To Request Preservice Review for Applied Behavior Analysis

Beginning in April 2026, you’ll need to call the customer service number on the member’s ID card to initiate preservice review of applied behavior analysis services for commercial members.

See Changes to Behavioral Health Utilization Management Program

The Illinois Health Care Protection Act established new requirements, effective Jan. 1, 2026, regarding utilization management and notification of behavioral health treatment.

Reminder: Changes to Prior Authorization Programs for Medicare Advantage

As of Jan. 1, 2026, we’re reviewing prior authorization requests for certain care categories that previously were reviewed by EviCore healthcare. Review what’s changed.

Watch for ClaimsXten^TM Update

We’ll implement code updates for the ClaimsXten auditing tool on or after March 16, 2026.

Review Prior Authorization Changes for Some Commercial and Government Plans

Effective Jan. 1, 2026, prior authorization requirements for certain commercial and government plans changed to reflect new, replaced or removed codes.

Avoid the Inappropriate Use of Antipsychotic Medications for Anxiety Disorders

Most antipsychotic medications aren’t approved for the treatment of anxiety disorders. We encourage prescribing providers to carefully assess symptoms, risks and benefits when considering medications for our members with anxiety disorders.

Remind Members About Cervical and Breast Cancer Screenings

Regular screening tests can help detect cancer early when it’s easier to treat. Learn about documenting these screenings in members’ medical records and other tips to close gaps in care.

See Our Clinical Review Criteria Overview

Our new training has helpful information regarding applicable medical policies, pharmacy guidelines and other criteria.

Annual Survey Measures Members’ Health Care Experiences

The Consumer Assessment of Healthcare Providers and Systems survey asks a sampling of our members to rate their experiences with their health care providers and plans. Learn about survey topics for Medicare Advantage and Medicaid plans.

Explore Learning Opportunities

We offer free webinars and workshops for providers who participate in our networks. View the schedule and sign up for sessions.

Update: Signed Forms Required for Hospice Prior Authorizations

Include the correct Healthcare and Family Services form, along with a signed Certificate of Terminal Illness, in your prior authorization submission.

See Updates to Medical Benefit Therapeutic Alternatives

When submitting prior authorization requests for certain drugs, you’ll receive recommendations on updated coverage for comparable drugs as of Jan. 1, 2026. This process can improve access to more affordable care for our commercial non‑HMO members.

Review Pharmacy Program Quarterly Update – Part 2

Changes were made to our drug lists and utilization management program. Learn about these and other pharmacy program updates.

See the Latest Pharmacy Prior Authorization Changes

We’re updating our standard pharmacy prior authorization programs. Changes affect members with prescription drug benefits administered by Prime Therapeutics^®. Review what’s changing as of Feb. 1, 2026.

Learn About Updates to Clinical Payment and Coding Policies

We regularly add and modify CPCPs as part of our ongoing policy review. See which policies were updated.

Review Active and Pending Medical Policies

Approved new or revised medical policies and their effective dates are usually posted on our website the first and 15th of each month. You can view all active and pending policies, as well as draft medical policies, and provide comments on draft policies. These policies may impact your reimbursement and your patients’ benefits.