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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 | May 10, 2024 | Oct 20, 2024 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | May 10, 2024 | Oct 20, 2024 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | May 10, 2024 | 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 | Oct 26, 2023 | Retired | 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 | May 10, 2024 | 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 | May 10, 2024 | Oct 20, 2024 | White blood cell growth factors, also known as granulocyte colony stimulating factors (g-csf), are... | View |
| M5.001.007 | Somatuline® Depot; Lanreotide | May 10, 2024 | 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) | May 10, 2024 | 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) | May 10, 2024 | 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) | May 10, 2024 | Oct 20, 2024 | 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 | May 10, 2024 | 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]) | May 10, 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 | May 10, 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 | May 10, 2024 | Feb 20, 2025 | Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... | View |
| M5.001.016 | Lumasiran for Primary Hyperoxaluria Type 1 | May 10, 2024 | Feb 20, 2025 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
| M5.001.017 | Hemophilia Antihemophilic Factor | May 10, 2024 | Apr 20, 2025 | Criteria for the management of anti-hemophilic factors 1. the prescription must be written by a... | View |
| M5.001.018 | Nucala® (mepolizumab) | May 30, 2024 | May 20, 2025 | Coverage is provided in the following conditions: universal criteria ï‚· must not be used in... | View |
| M5.001.019 | Fasenra® (benralizumab) | May 30, 2024 | May 20, 2025 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | Jun 01, 2024 | Jun 20, 2025 | Initial treatment givosiran may be considered medically necessary if all of the following conditions are... | View |
