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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 |
|---|---|---|---|---|---|
| 02.002.003 | Total Artificial Hearts And Implantable Ventricular Assist Devices | Sep 18, 2024 | Sep 20, 2025 | A ventricular assist device (vad) is mechanical support attached to the native heart and vessels to augment... | View |
| 02.002.038 | Intravascular Lithotripsy | Oct 24, 2024 | Oct 20, 2025 | Intravascular lithotripsy (ivl) delivers unfocused, circumferential, pulsatile mechanical energy to safely... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 11, 2024 | Sep 20, 2025 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 10.001.014 | Telemedicine | Oct 24, 2024 | Oct 20, 2025 | Telemedicine is defined as the exchange of medical information between the sites through electronic... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | Jun 25, 2024 | Jun 20, 2025 | Acute hepatic porphyria (ahp) is a rare disease with a prevalence of 5 to 10 cases/100,000 people in the us... | View |
| M5.001.021 | Biological Treatments for Refractory Myasthenia Gravis | Jun 25, 2024 | Jun 20, 2025 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | Oct 09, 2024 | Jun 20, 2025 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M7.001.001 | May 10, 2024 | Policy Archived | Studies have generally found that laser treatment can be effective at lightening port wine stains. the... | View | |
| MP.001.001 | Dose rounding of drugs covered under the Medical Benefit | May 10, 2024 | May 20, 2025 | ... | View |
| MP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... | View |
| PP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 10, 2024 | May 20, 2025 | ... | View |
| PP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... | View |
