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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| 02.002.016 | Cardiac Hemodynamic Monitoring For The Management Of Heart Failure In The Outpatient Setting | Jun 2026 | A variety of outpatient cardiac hemodynamic monitoring devices are intended to improve quality of life and... | View |
| 02.002.038 | Intravascular Lithotripsy | Aug 2026 | Intravascular lithotripsy (ivl) delivers unfocused, circumferential, pulsatile mechanical energy to safely... | View |
| 07.001.151 | Prostatic Urethral Lift | Sep 2025 | Benign prostatic hyperplasia (bph) is a common condition in older individuals that can lead to increased... | View |
| 10.001.014 | TELEMEDICINE | Aug 2026 | Telemedicine is the remote exchange of medical information through secure electronic communication to support... | View |
| M3.001.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Aug 2026 | ... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | May 2026 | 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 | Jul 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | May 2026 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M5.001.024 | Adstiladrin® (nadofaragene firadenovec-vncg) | Jun 2026 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| M7.001.001 | Laser Treatment of Wine Stains | May 2024 | 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 2026 | ... | View |
| MP.001.002 | Leuprolide | May 2024 | (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 2026 | ... | View |
| PP.001.002 | Leuprolide | May 2026 | (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... | View |
| PP.001.004 | Coverage Guideline for Orphan Drugs and Off-Label and Labeled Use of FDA Approved Drugs | Jan 2026 | Triple s salud has a procedure designed to ensure the evaluation of requests for coverage of covered... | View |