Practice guidelines

To help provide our members with consistent, high-quality care that uses services and resources effectively, we have chosen certain clinical guidelines to help our providers. These include treatment protocols for specific conditions, as well as preventive health measures.

These guidelines are intended to clarify standards and expectations. They should not:

  • Take precedence over your responsibility to provide treatment based on the member’s individual needs
  • Substitute as orders for treatment of a member
  • Guarantee coverage or payment for the type or level of care proposed or provided

Acute Stress Disorder and Posttraumatic Stress Disorder

American Psychiatric Association (APA): Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder (reviewed and approved 8/15).

Alcohol Abuse

National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping Patients Who Drink Too Much, A Clinician’s Guide, 2005 Edition (reviewed and approved 5/16).

Asthma

National Heart, Lung and Blood Institute (NHLBI)-Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3) Aug. 2008 Update (reviewed and approved 6/16).

Asthma and Pregnancy

Management of Asthma and Pregnancy (reviewed and approved 12/15) Click here to access the American Congress of Obstetricians and Gynecologists (ACOG) updates (approved 12/16).

Bipolar Disorder

APA: Treatment of Patients With Bipolar Disorder (reviewed and approved 8/15).

Borderline Personality Disorder

APA: Treatment of Patients With Borderline Personality Disorder (reviewed and approved 8/15).

Chronic Kidney Disease

National Kidney Foundation: The KDOQI Clinical Practice Guidelines for Chronic Kidney Disease Care and Hemodialysis Adequacy, 2015 Update in the American Journal of Kidney Diseases, Nov. 2015 issue (reviewed and approved 5/16).

Chronic Obstructive Pulmonary Disease

Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease – Updated 2016 (reviewed and approved 5/16). GUIDELINE TO USE

Coronary Artery Disease

2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease (reviewed and approved 5/16).

2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease (reviewed and approved 5/16).

Crohn's Disease

Management of Crohn’s Disease in Adults. 2009. Gary R. Lichtenstein MD, Stephen B. Hanauer MD, William J. Sandborn MD, and the Practice Parameters Committee of the American College of Gastroenterlogy (reviewed and approved 5/16).                                                                

Diabetes

American Diabetes Association (ADA). Standards of Medical Care in Diabetes-2016.

Diagnosis and Management of Stable Chronic Obstructive Pulmonary Disease

A Clinical Practice Guideline Update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society and European Respiratory Society, 2011 (reviewed and approved 5/16). FOR INFORMATION ONLY

Eating Disorders

APA: Treatment of Patients With Eating Disorders (reviewed and approved 8/15).

Gestational Diabetes

Management of Gestational Diabetes and Pregnancy (reviewed and approved 12/15). Click here to access ACOG updates (approved 12/16).

Heart Failure

ACCF/AHA. Guideline for Diagnosis and Management of Heart Failure 2013 (reviewed and approved 6/16).

HIV/AIDS (FOR BEHAVIORAL HEALTH CLINICIAN USE)

APA: Treatment of Patients With HIV/AIDS (reviewed and approved 8/15).

HTN & Pregnancy

Management of Chronic Hypertension and Pregnancy (reviewed and approved 12/15). Click here to access ACOG updates (approved 12/16).

Major Depressive Disorder-Adult

APA: Treatment of Patients with Major Depressive Disorder (reviewed and approved 8/15) .

Preeclampsia and Eclampsia

Preeclampsia and Eclampsia (reviewed and approved 11/14). Click here to access ACOG updates (approved 12/16).

Prenatal and Postpartum

Prenatal and Postpartum (reviewed and approved 11/14). Click here to access ACOG updates (approved 12/16).

Preterm labor

Management of Preterm Labor (reviewed and approved 12/15). Click here to access ACOG updates (approved 12/16).

Schizophrenia

APA: Treatment of Patients With Schizophrenia (reviewed and approved 8/15).

Substance Use Disorders

APA: Treatment of Patients With Substance Use Disorders (reviewed and approved 8/15).

Substance Abuse & Pregnancy

Management of Substance Abuse and Pregnancy (reviewed and approved 12/15). Click here to access ACOG updates (approved 12/16).

Attention-Deficit/Hyperactivity Disorder (ADHD) (FOR PRIMARY CARE PRACTIONER USE)

American Academy of Pediatrics (AAP): Clinical Practice Guideline for … ADHD in Children and Adolescents (reviewed and approved 8/15).

Attention-Deficit/Hyperactivity Disorder (ADHD) (FOR BEHAVIORAL HEALTH CLINICIAN USE)

American Academy of Child & Adolescent Psychiatry (AACAP): Practice Parameter for the Assessment and Treatment of Children and Adolescents With ADHD (reviewed and approved 8/15).

Autism

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Autism Spectrum Disorder (reviewed and approved 8/15).

Bipolar Disorder

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Bipolar Disorder (reviewed and approved 8/15).

Depressive Disorders

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Depressive Disorders (reviewed and approved 8/15).

Eating Disorders

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Eating Disorders (reviewed and approved 8/15).

Electroconvulsive Therapy

AACAP: Practice Parameter for Use of Electroconvulsive Therapy With Adolescents (reviewed and approved 8/15).

Post-traumatic Stress Disorder

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Posttraumatic Stress Disorder (reviewed and approved 8/15).

Schizophrenia (revised)

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Schizophrenia (reviewed and approved 8/15).

Substance Use Disorders

AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders (reviewed and approved 8/15).

These health maintenance guidelines for adults and children are based on recommendations from national medical associations and authorities.

*Source: Centers for Disease Control and Prevention (CDC) , 2015

 

Bright Futures

Recommendations for Preventive Pediatric Health Care (reviewed and approved 6/16).

Preventive Dental

American Academy of Pediatric Dentistry’s Guideline on Periodicity of Examination, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents. Revised 2013 (reviewed and approved 12/15).

Universal Cholesterol Screening for Children

Sponsored by National Institutes of Health’s, National Heart, Lung, and Blood Institute’s and in Official Journal of the AAP Dec 2011: Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report (reviewed and approved 8/16).

 

Preventive Health Guidelines

The next three groups are U.S. Preventive Services Task Force published recommendations (found on-line 3/15/16 and reviewed and approved 5/25/16).

 

Perinatal

This information is a summary of preventive health service recommendations for healthy pregnant women with normal risks. 

Recommended preventive health screenings for pregnant women
Asymptomatic Bacteriuria Urine culture at 12‐16 weeks gestation or at first prenatal visit if later.
Breastfeeding Counseling Interventions during pregnancy and after birth to promote and support breastfeeding.
Depression During pregnancy and post-partum.   Ensure accurate diagnosis, effective treatment and appropriate follow-up. 
Gestational diabetes Asymptomatic women after 24 weeks gestation.
Hepatitis B virus (HBV) First prenatal visit.
Human immunodeficiency virus (HIV) Screen all during pregnancy, including those who present in labor who are untested and whose HIV status is unknown.
Syphilis Screen all during pregnancy.
Tobacco use Ask all pregnant women about tobacco use, advise them to stop using tobacco and provide behavioral interventions for cessation.  
Vaccinations Refer to the Centers for Disease Control and Prevention (CDC) on-line at  Immunization Schedules | CDC/ACIP

 

 

Adolescents & Children

This information is a summary of preventive health service recommendations for healthy adolescents and children with normal risks. 

Recommended preventive health screenings for adolescents & children
Obesity Children and adolescents 6‐18 years old.  Offer or refer to comprehensive, intensive behavioral intervention to promote improvement in weight status.
Depression Adolescents aged 12‐18 years.   Screen for major depressive disorder.  Implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up.
Human immunodeficiency virus (HIV) Adolescents 15 years of age and over.See the Clinical Considerations for more information about screening intervals.
Tobacco use prevention School‐age children and adolescents:  Primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use.  See the Clinical Considerations for more information on effective interventions.
Vision At least once between the ages of 3‐5 years to detect the presence of amblyopia or its risk factors.
Vaccinations Refer to the Centers for Disease Control and Prevention (CDC) on-line at Immunizations Schedules / CDC/ACIP

 

 

Adults

This information is a summary of preventive health service recommendations for healthy adults with normal risks. 

Recommended preventive health screenings for adults
Men & Women
Alcohol Misuse Adults 18 years of age and older:  Provide persons engaged in risky or hazardous drinking with brief behavioral counseling to reduce misuse.
Depression  General adult population.  Ensure accurate diagnosis, effective treatment and appropriate follow-up. 
High Blood Pressure Adults 18 years of age and older. Obtain measurements outside of the clinical setting for diagnostic confirmation before starting treatment (see the Clinical Considerations section).
Hepatitis C (HCV) Adults born between 1945 and 1965: offer one time screening. The USPSTF also recommends screening for hepatitis C virus (HCV) infection in persons at high risk for the infection.   
Human immunodeficiency virus (HIV) Adults to age 65 years of age. See the Clinical Considerations for more information about screening intervals.
Lipid Disorders (Cholesterol) Men 35 years of age and older.Screen men age 20-35 and women age 20 and older if at risk for coronary heart disease.
Obesity All adults: Offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
Tobacco use Ask all adults about tobacco use, advise to stop using tobacco and provide behavioral interventions and U.S. Food and Drug Administration (FDA)–approved pharmacotherapy for cessation to adults who use tobacco. 
Vaccinations Refer to the Centers for Disease Control and Prevention (CDC) on-line at Immunization Schedules / CDC/ACIP
Men
Abdominal Aortic Aneurysm One-time screening for abdominal aortic aneurysm with ultrasonography in men ages 65 to 75 years who have ever smoked.
Women
Chlamydia and gonorrhea Screen sexually active women 24 years of age and younger
Osteoporosis Women 65 years of age and older
Intimate Partner (domestic) Violence Women of childbearing age. Provide or refer women who screen positive to intervention services.  See the Clinical Considerations or more information on effective interventions.