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Overview

What Are Medical Policies?

Medical policies determine under what circumstances medical services, procedures, devices and drugs may be eligible for coverage. These medical policies include detailed clinical criteria that are applied after a member's contractual benefit has been determined.

View our alphabetical listing of Medical Policies or use the search function.

Medical Policies are Based on Proven Merits and Scientific Evidence 

Wellmark bases its medical policies on:

• Data from peer-reviewed scientific literature
• Criteria developed by specialty societies
• Guidelines adopted by other health care organizations

Wellmark evaluates medical technologies based on the following criteria:

• The technology must have final approval from the appropriate governmental regulatory bodies
• The scientific evidence must permit conclusions concerning the effect of technology on health outcomes
• The technology must improve the net health outcomes
• The technology must be as beneficial as any established alternatives
• The improvement must be obtainable outside the investigational settings

To request Wellmark’s consideration of a new technology, i.e., biologic, drug, procedure, or device, or new use of an existing technology, please download the technology assessment form  (43KB).

Network Providers Contribute, Too

Network providers help develop medical policies and regularly sit on Wellmark's Medical Policy Advisory Council (MPAC). For complex or controversial issues, Wellmark invites local physician experts to advise MPAC. MPAC may consult further with external technology assessment services and databases, local experts, and scientific literature and other sources.

While scientific evidence-based methodology guides decisions, MPAC also considers the social and economic impact on patients and providers.

Changes to Medical Policies

Medical technology is constantly evolving and these medical policies are subject to change without notice, except as required by law. Additional medical policies may be developed from time to time and some may be withdrawn from use.

Medical policies designated as “Active Policy; No Longer Scheduled for Routine Literature Review” are used to process claims, but are not subject to Wellmark’s annual literature review.

Wellmark's medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and are not offers of coverage or medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies are subject to change without notice.