Overview

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Medical Policies & Clinical UM Guidelines 
Welcome to the Simply Health medical policy & clinical UM guideline website that provides access to electronic versions of medical policies and clinical UM guidelines.  
To view medical policies & clinical UM guidelines, click on the medical policy or UM guideline tab above. You can also use the “search” feature, which is housed in the top navigation, or click this link: Click Here to Search  
Dates associated with medical policies and clinical UM guidelines  
Each medical policy and clinical UM guideline includes a Last Review Date and Publish Date. A medical policy or clinical UM guideline is made available on our public websites on its Publish Date. While the Publish Date is enterprise-wide, the actual implementation date may differ, depending on notification requirements. Local health plans will determine if new or revised medical policies and clinical UM guidelines require advance provider notification, based upon state laws, provider contracts and other considerations.  
Medical policy and clinical UM guidelines do not contain an implementation effective date which is the date that a health plan may begin using the new or updated medical policy or clinical UM guideline. The Implementation Date may be the same as the Publish Date when an updated document is an expansion of current criteria. When a new document or an update to an existing document that is more restrictive is published, the implementation date is determined by the local health plan since requirements regarding provider notification vary based upon state laws, provider contracts and other considerations.  
Third Party Criteria  
In addition to the documents we develop and maintain for coverage decisions, we may adopt criteria developed and maintained by third party organizations. Please click on the UM Guidelines tab above and choose ‘By Category’ for information on the guidelines available for use.  
Prescription Drug Documents  
Beginning March 1, 2019, the clinical criteria for drugs and biologics paid under the medical benefit may be accessed at the following website for certain Medicare/Medicaid markets:  
Development of clinical criteria for oncology medical injectable drugs is targeted for mid-2019. At that time, clinical criteria for all drugs paid under the medical or pharmacy benefit will be available for review at the above website. 
Simply Healthcare Plans, Inc. is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. H5471_SHPM01K2360 Approved

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