How we read coverage policies

Coverage questions have more than one right answer at once, because more than one document can apply. This page sets out which document wins when two disagree, the labels this site uses for what a document says, and the promise that every fact is read again each January and July.

By the Covered Weight editorial team. Research and sourcing by Evan Reid.

The hierarchy

When two documents disagree, the one closest to the money wins. In descending order of authority for a given reader:

Federal statute and regulation. Where Congress has excluded a category of drug from a program, no plan under that program can add it back.
National coverage determinations. A federal decision that binds everywhere the program operates.
Local coverage determinations. A regional decision that fills the space a national one leaves open.
State program documents. A state plan, a preferred drug list, a provider manual. These decide a state program's answer, and they are the reason that answer changes at a state line.
Commercial medical policy. An insurer's published criteria for a treatment, applied to the plans it insures.
The plan document itself. For a self-funded employer plan this is the top of the list, not the bottom: it can exclude a treatment the insurer's own policy would cover, and no state rule reaches it.

That last line is why this site asks who pays your claims before it answers anything. Read the front page for the short version of that question.

What each label means

A coverage answer is not a yes or a no. It is one of nine states in the data, which collapse into five a reader has to distinguish. The difference between a drug being absent from a list and being affirmatively excluded is the difference between asking for an exception and having nowhere to ask.

What each label means

Covered: On the benefit, with no gate in front of it.
Covered with conditions: On the benefit once a requirement is met first.
Depends on your plan: Your own plan document decides. No state rule reaches it.
Not covered: The document says no. Read the note for whether an exception exists.
Not published: We looked and nothing is published. The cell names who to ask.

Why we publish that we could not find something

A coverage table with blank cells is useless, and every table in this field has them. When a document is silent, this site records that as a finding rather than a gap: what terms were searched, in which document, on what date, and the office that can answer instead, with the exact question to ask. The hatched cell in the legend above is that state, and it is deliberately impossible to mistake for a rendering bug.

What a citation on this site contains

A bare citation cannot be checked, so it is not enough. Every fact points at a document record carrying the title as printed on the document, the section the fact sits under, a verbatim quote containing the fact, the effective date, and the date we read it. Where the document is the kind that gets replaced rather than versioned, which is most drug lists, the record also carries an archived copy.

A document record also states its own scope: which jurisdictions it governs, which plan types, which drugs, and which conditions. A citation can be right about the state and wrong about the plan type, and recording all four is what makes that checkable rather than a matter of trust.

January and July

Drug lists and medical policies reset at the start of a plan year and again mid-year. Every fact on this site is read again in those two months, and each one carries the date it was last read so a reader can see for themselves rather than take our word for it. A fact past its review date is flagged rather than left to age quietly.

The editorial process describes the checks that run before any of it reaches a page.