Medical Policies
Medical policies are documents that define the plan coverage for technologies, procedures and treatments. The statements of medical necessity in the policies, about whether a technology, procedure, treatment, supply, equipment, drug or other service improves the health outcome of the population for which said technology or treatment was designed are based on scientific evidence, clinical studies and professional opinions from our providers and recognized medical organizations.
Each document displayed on this website is provided for informational purposes only and is not an authorization, explanation of benefits, or contract. Receiving benefits is subject to satisfaction of all terms and conditions of coverage. Medical technology is constantly changing, and we reserve the right to periodically review and update our policies.
| ID | Title | Last Review | Next Review | Description | Access |
|---|---|---|---|---|---|
| M5.001.001 | Viscosupplementation Therapy For Knee | Oct 26, 2023 | Oct 20, 2024 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | Oct 26, 2023 | Oct 20, 2024 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | Oct 26, 2023 | Oct 20, 2024 | Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... | View |
| M5.001.004 | Pegfilgrastim | Sep 20, 2023 | Oct 26, 2023 | Pegfilgrastim is a colony stimulating factor (csf) that acts on hematopoietic cells by binding to specific... | View |
| M5.001.005 | Bevacizumab – Bevacizumab Biologics for Oncologic Uses | Oct 26, 2023 | Oct 20, 2024 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| M5.001.006 | CSF Hematopoietic Colony Stimulating Factors | Oct 26, 2023 | Oct 20, 2024 | G-csf is classified as a recombinant hematopoietic stimulant. this is not a cancer chemotherapy agent. it is... | View |
| M5.001.007 | Somatuline® Depot; Lanreotide | Dec 04, 2023 | Dec 20, 2024 | Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... | View |
| M5.001.008 | Simponi ARIA® (golimumab) | Dec 04, 2023 | Dec 20, 2024 | Simponi aria® (golimumab) may be considered medically necessary in patients is at least 18 years of... | View |
| M5.001.009 | Stelara® (ustekinumab) | Dec 04, 2023 | Dec 20, 2024 | Stelara® (ustekinumab) may be considered medically necessary if the following conditions are met: patient... | View |
| M5.001.010 | Infliximab (Remicade, Inflectra, Renflexis, Avsola and Unbranded Infliximab) | Oct 13, 2023 | Dec 20, 2023 | Infliximab (remicade) is a tumor necrosis factor α (tnf-α) blocking agent approved by the u.s. food and... | View |
| M5.001.011 | Erythropoiesis Stimulating Agents | Dec 04, 2023 | Dec 20, 2024 | Endogenous erythropoietin is a glycoprotein hematopoietic growth factor that regulates hemoglobin levels in... | View |
| M5.001.012 | Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Deseases | Dec 04, 2023 | Dec 20, 2024 | Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... | View |
| M5.001.013 | Ruconest (C1 Esterase Inhibitor [recombinant]) | Feb 19, 2024 | Feb 20, 2025 | Coverage is provided in the following conditions: • patient is at least 13 years of age; and universal... | View |
| M5.001.014 | Immune Globulin | Feb 15, 2024 | Feb 20, 2025 | Immune globulin (also referred to as gamma globulin or immunoglobulin) is a therapeutic compound prepared... | View |
| M5.001.015 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients | Feb 15, 2024 | Feb 20, 2025 | Patisiran only it is given as intravenous infusion based on body weight. for individuals less than 100... | View |
| M5.001.016 | Lumasiran for Primary Hyperoxaluria Type 1 | Feb 16, 2024 | Feb 20, 2025 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
