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e. IEHP has created UM Subcommittee Approved Authorization Guidelines to serve as one of the sets of criteria for medical necessity decisions. Our goal in creating this page is to provide you with easily accessible electronic versions of IEHP’s UM guidelines. IEHP utilizes a variety of sources in developing our UM guidelines which include: Medicare and Medi-Cal’s coverage policy statements Evidence in the peer-reviewed published medical literature Technology assessments and structured evidence reviews Evidence-based consensus statements Expert opinions of healthcare Providers Evidence-based guidelines from nationally recognized professional healthcare organizations and public health agencies. IEHP is also licensed to use MCG Guidelines, Apollo Medical Review Criteria, and InterQual to guide in utilization management decisions. Since medical technology is constantly evolving, our clinical guidelines are subject to change without prior notification. Additional UM Subcommittee Guidelines may be developed as needed or may be withdrawn from use. Please note that benefits may vary based on Member’s line of business; therefore, certain services discussed in the UM Subcommittee Guidelines may not be a covered benefit. Table of Contents (PDF) Providers may obtain information about criteria, either in general or relating to specific UM decisions, from IEHP upon request by contacting the IEHP UM Department. Please contact the IEHP Provider Relations Team at (909) 890-2054 to be connected to the UM Department.  Behavioral Health Behavioral Health Treatment (BHT) Criteria (PDF) Criteria for Multidisciplinary Diagnostic Treatment (PDF) Community Supports Services Community Transition Services Nursing Facility Transition to a Home (PDF) Nursing Facility Transition-Diversion to Assisted Living (PDF) Housing Deposits (PDF) Housing Transition Navigation Services (PDF) Housing Tenancy and Sustaining Services (PDF) Asthma Remediation (PDF) Environmental Accessibility Adaptations (Home Modifications) (PDF) Medically Tailored Meals (PDF) Sobering Centers (PDF) Recuperative Care (PDF) Short-Term Post-Hospitalization Housing (PDF) Diagnostic Testing Elastography (PDF) Inflammatory Bowel Disease Serology (PDF) Vestibular Autorotation Test (PDF) Gynecology and Obstetrics Fetal Non-Stress Testing (PDF) Neurology Bone Marrow Transplant in Treatment of Multiple Sclerosis (PDF) Pain Management Referrals to Pain Management Specialist (PDF) Pharmacy Biosimilar Products (PDF) CAR-T Therapy (PDF) Surgical Procedures Adolescent Bariatric Consultation and Surgery (PDF) Natural Orifice Transluminal Endoscopic Surgery (PDF) Other Allocation of Limited Critical Care Resources During a Public Health Emergency (PDF) Complementary and Alternative Medicine or Holistic Therapies (PDF) Congregate Living Health Facilities (PDF) Criteria for Custodial Care: Medi-Cal (PDF) Enhanced Care Management (PDF) Hair Removal Guideline (PDF) My Path (A Palliative Care Approach) (PDF) Tertiary Care Center Referral Requests (PDF) Transitional Care Medicine (PDF) Transportation Criteria (PDF)   You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.

You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking Adobe Acrobat Reader. By clicking on this link, you will be leaving the IEHP website. Medicare: For IEHP DualChoice (HMO D-SNP) - Medicare-Medicaid Plan - Formulary and Criteria information, please click here IEHP DualChoice (HMO D-SNP). Medicaid: On January 7, 2019, Governor Gavin Newsom issued Executive Order N-01-19 (EO-N-01-19) for achieving cost-savings for drug purchases made by the state. A key component of EO N-01-19 requires the Department of Health Care Services (DHCS) transition all Medi-Cal pharmacy services from managed care (MC) to fee for service (FFS). Click here to go to the “DHCS Medi-Cal Rx” page on IEHP website Click here to go to “Medi-Cal Rx: Transition” page on DHCS website Updated April 7, 2021, this document describes DHCS’ multi-faceted pharmacy transition policy, inclusive of “grandfathering” previously approved PAs from managed care and fee-for-service, as well as a 180-day period with no PA requirements for existing prescriptions, to help support the Medi-Cal Rx transition. During this transition period, Magellan will provide system messaging, reporting and outreach to provide for a smooth transition to Medi-Cal Rx. Click here to view “Medi-Cal Rx Pharmacy Transition Policy” from DHCS website To view Drug Criteria Referenced in Summary Table - Click Links Below: Clinical Practice Guidelines - CPGs Drug Prior Authorization Criteria HP Acthar (repository corticotropin injection) (PDF) Nucala (PDF) Spinraza (nusinersen) (PDF) Synagis (PDF) Xolair (omalizumab) (PDF)  Drug Class Prior Authorization Criteria Growth Hormones (PDF) Immuno Globulins (PDF) Therapeutic Agents in Rheumatic And Inflammatory Diseases (PDF) Zynteglo (PDF) Pharmacy Policies Discharge Policy (PDF) Drug Trial and Failure (PDF) High Daily Morphine Milligram Equivalent (PDF) IEHP Drug Prior Authorization Policy (PDF) Intradialytic Parenteral Nutrition (IDPN) Policy (PDF) Non-Formulary Drug (PDF) Non-Sterile Compounded Medication (PDF) Off-Label Indication Policy (PDF) Pharmacy Drug Management Program for Pain (PDF) Quantity Limit Policy (PDF) Information on this page is current as of June 02, 2023.

HP 臨床藥師團隊負責生產您的藥物，確保您所使用的藥物劑量符合您的健康狀況。若您是符合 MTM 計畫資格的會員，我們將會發送一封信函給您。除非您選擇不加入，否則您將自動投保計畫。符合資格的會員投保計畫無需花費任何費用。 誰可能符合資格？  本計畫的部分合格會員可能僅享有 IEHP 的 Medi-Cal 給付，   或者可能已經投保 IEHP DualChoice Cal MediConnect Plan (Medicare-Medicaid 計畫)。該等會員必須符合相關條件，且將會獲得 Medicare MTM 計畫的服務。(請參閱下列說明。)  MTM 服務包括哪些？  IEHP 的  MTM 服務包括 下列核心要素： 藥物治療審查 藥物教育 - 包括藥物行動計畫 疾病管理 我們的 IEHP 臨床藥師團隊會審查會員的藥物、家族病史、疾病狀態與藥物治療目標。該團隊會依據完整審查結果，為會員與提供者提供建議。  持照藥劑師與技師團隊將會與您的醫師 (或其他提供者) 及藥局合作提供完整照護。我們也會與照護管理團隊合作，為會員提供「全方位健康」照護。 Medicare MTM 計畫 IEHP 臨床藥師團隊為符合下列條件的 IEHP DualChoice 會員提供 MTM 服務，不另收取費用： 患有多種疾病； 使用許多處方藥； 需支付高額藥物費用 加入此計畫後，您將收到一份包含詳細資訊的郵寄資料包。此資料包也會提供如何退出計畫的相關資訊，以便您選擇不加入計畫時使用。若您決定不參與計畫，您獲得 IEHP DualChoice 給付的狀態及相關資格將不會有任何變化。誠摯希望您在符合資格時能夠加入，此計畫完全免費，還可協助您更好地管理您的藥物。  MTM 計畫包括年度綜合用藥審查 (CMR) 及針對性用藥審查 (TMR)。以下為 MTM 服務的部分內容： 綜合用藥審查  (CMR) IEHP 臨床藥劑師將透過電話為您提供年度綜合用藥審查服務。藥劑師會逐一確認您的藥物，以確保您所使用的藥物符合您的健康狀況，並協助您避免藥物相互作用等。  在完成您的 CMR 後，我們會將您的藥物行動計畫 (Medication Action Plan, MAP) 及個人藥物清單 (Personal Medication List, PML) 郵寄給您。您可致電會員服務中心並要求與臨床藥師團隊通話，以取得相關 MTM 服務文件及個人藥物清單的副本。 針對性用藥審查  (TMR) IEHP 臨床藥師團隊也會在一年當中提供 TMR 服務，審查參與計畫之 IEHP DualChoice 會員的藥物。該團隊會每三個月為所有保險受益人進行一次 TMR。保險受益人會透過郵件收到 TMR 建議，其初級照護提供者則可能會透過傳真收到相關建議 (若 IEHP 臨床藥師團隊認定有必要)。 符合 CMR 或 TMR 服務資格的 IEHP DualChoice 會員如需瞭解詳細資訊，可致電 1-877-273-IEHP (4347)，服務時間為 (太平洋標準時間) 每天早上 8 點至下午 8 點，假日亦提供服務。TTY 使用者請撥 1-800-718-4347。  按一下此處獲取空白個人藥物清單。 資格條件 該等 MTM 計畫服務可能有一些適用的資格條件，且不屬於福利。MTM 計畫服務適用於符合下列條件的會員： 1.會員罹患至少三 (3) 種下列疾病： 骨骼疾病 - 關節炎 - 骨質疏鬆症 骨骼疾病 - 關節炎 - 類風濕性關節炎 慢性心臟衰竭 (Chronic Heart Failure, CHF) 糖尿病 血脂異常 末期腎臟病 (End-Stage Renal Disease, ESRD) 高血壓 心理健康慢性疾病/殘障心理健康疾病 呼吸系統疾病 – 哮喘 呼吸系統疾病 – 慢性阻塞性肺病 (Chronic Obstructive Pulmonary Disease, COPD) 2. 醫師為會員開立至少五 (5) 種不同的處方藥，以治療下列疾病： 血管緊張素 I 型轉化酶抑制劑 血管緊張素 II 型受體阻斷劑 (Angiotensin II Receptor Blocker, ARB) 抗憂鬱劑 降血脂藥 降血壓藥 抗精神病藥物 乙型阻斷劑 支氣管擴張劑 鈣通道阻斷劑 疾病調節抗風濕藥物 (Disease-Modifying Anti-Rheumatic Drug, DMARD) 利尿劑 胰島素 口服降血糖藥 選擇性血清素再吸收抑制劑 (Selective Serotonin Reuptake Inhibitor, SSRI) 腫瘤壞死因子 (Tumor Necrosis Factor, TNF) 吸入式皮質類固醇 擬鈣製劑 強心配糖體 聚落刺激因子 昇糖素類似胜肽 糖皮質激素 腦啡肽酶抑制劑 非類固醇消炎止痛藥 (NSAID) 磷酸鹽結合劑 維生素 D 類似物  3.前三個月可能須支付 1,174 美元 (4,696 美元的四分之一) 的藥物費用。 如欲進一步瞭解 MTM，請致電  IEHP DualChoice 會員服務中心，電話：1-877-273-IEHP (4347)。服務時間為 (太平洋標準時間) 每天早上 8 點至晚上 8 點，假日亦提供服務。TTY 使用者 請 撥 1-800-718-4347。 此頁面資訊為截至 2021 年 10 月 8 日的資訊。 H5355_CMC_22_2246727  

n about cholesterol and how it affects your health as well as lifelong habits for a healthy weight. Click here to register for this Webex class   Session Number:  26324187245 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

how diabetes and tobacco affect your heart and ways to protect your heart from diabetes and tobacco. Click here to register for this Webex class   Session Number:  26306529583 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

ow to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity.  Click here to register for this WebEx class   Session Number: 26328154793 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

make small healthy changes to  food/drinks choices. Click here to register for this WebEx class   Session Number: 26332729367 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

c: Staying on Course: You will learn how to get past frustration even when you feel stuck. Click here to join register for this WebEx class   Session Number:  26334427185 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

rn about cholesterol and how it affects your health as well as lifelong habits for a healthy weight. Click here to register for this Webex class   Session Number:  26302869284 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

to record your results in a log book and why checking blood sugar is needed in diabetes care. Also, see which other tests you need to monitor your general health.  Click here to register for this Webex class   Session Number: 26345912038 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

at happens in the lungs when asthma symptoms start, learn about asthma triggers, and how to avoid asthma attacks. Click here to register for this WebEx class   Session Number: 26303046816 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

ze symptoms of low and high blood sugar levels, how to treat them, and how to prevent them. Also, learn to manage blood sugar levels when you get sick. Click here to register for this Webex class   Session Number: 26344912265 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

at happens in the lungs when asthma symptoms start, learn about asthma triggers, and how to avoid asthma attacks. Click here to register for this WebEx class   Session Number: 26314191432 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

symptoms of low and high blood sugar levels, how to treat them, and how to prevent them. Also, learn to manage blood sugar levels when you get sick. Click here to register for this Webex class   Session Number: 26337069256 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

pens in the lungs when asthma symptoms start, learn about asthma triggers, and how to avoid asthma attacks. Click here to register for this WebEx class   Session Number: 26349460053 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

to eat healthy on a budget, how to make healthy selections when dining out, and it also reviews the importance of physical activity. Click here to register for this WebEx class   Session Number: 26321543021 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

d managing weight.  Click here to register for this WebEx class   Session Number: 26332058753 Download Webex for Apple users Download Webex for Android users Download Webex for PC users  

ow diabetes and tobacco affect your heart and ways to protect your heart from diabetes and tobacco. Click here to register for this Webex class   Session Number:  26339970200 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

ways to cope, and strategies to talk to your doctor.  Click here to register for this Webex class   Session Number: 26349490166 Download Webex for Apple users Download Webex for Android users Download Webex for PC users

th Care Services (DHCS), California Advancing and Innovating Medi‐Cal (CalAIM) is a long‐term commitment to transform and strengthen Medi‐Cal, offering Californians a more equitable, coordinated, and person‐centered approach to maximizing their health and life trajectory.1 DHCS Goals For CalAIM 2 Identify and manage comprehensive needs through whole person care approaches and social drivers of health. Improve quality outcomes, reduce health disparities, and transform the delivery system through value-based initiatives, modernization, and payment reform. Make Medi‐Cal a more consistent and seamless system for enrollees to navigate by reducing complexity and increasing flexibility. Resource Links DHCS CalAIM page DHCS CalAIM Transformation Infographic (PDF) DHCS Medi-Cal Alignment Primer (PDF) IEHP Enhanced Care Management IEHP Enhanced Care Management (Member Page) IEHP Community Support Services IEHP Community Support Services (Member Page)   1,2https://dhcs.ca.gov/calaim You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here.