Medical Policies for Molina Healthcare

Please note that the following policies are posted for reference only. Based on the member’s benefit coverage, Evolent policies may be utilized for determinations. Health Plan policy or State mandated policy may be used before Evolent policy based on the Health Plan. Medicare determinations will follow the clinical criteria set forth by CMS using National Coverage Determinations (NCD), Local Coverage Determinations (LCD), CMS Guidance documents or the five Compendia approved by CMS for cancer drugs. The policy versions posted may not apply to all health plans. At any time, you may request the specific clinical criteria used in a determination decision.