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
M3.001.001 Therapeutic Radiopharmaceuticals for Prostate Cancer Aug 2025 ... View
M3.001.002 Radio 223 Injection (Xofigo) May 2025 Approximately 240,000 men in the united states are expected to be diagnosed with prostate cancer in 2016.... View
M5.001.001 Viscosupplementation Therapy For Knee May 2026 Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... View
M5.001.002 Rituximab May 2026 Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... View
M5.001.003 Trastuzumab – Trastuzumab Biologics Sep 2025 Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... View
M5.001.005 Bevacizumab Dec 2025 Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... View
M5.001.006 G-Csf Filgrastim May 2026 White blood cell growth factors, also known as granulocyte colony stimulating factors (g-csf), are... View
M5.001.007 Somatuline® Depot; Lanreotide May 2026 Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... View
M5.001.008 Simponi ARIA® (golimumab) May 2026 Golimumab is in a class of drugs called biologics. golimumab is a treatment for adults with moderate to... View
M5.001.009 Stelara® (ustekinumab) May 2026 Stelara is a human igg1κ monoclonal antibody that binds with high affinity and specificity to the p40... View
M5.001.010 Infliximab May 2026 Infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent approved by the... View
M5.001.011 Erythropoiesis Stimulating Agents May 2026 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 Diseases Sep 2025 Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... View
M5.001.013 Ruconest May 2026 C-1 esterase inhibitor protein is one of nine complement proteins found in the blood that works with the... View
M5.001.014 Immune Globulin May 2026 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 2026 Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... View
M5.001.016 Lumasiran for Primary Hyperoxaluria Type 1 May 2026 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 2026 The hemophilias are a group of related bleeding disorders that most commonly are inherited. inherited... View
M5.001.018 Nucala® (mepolizumab) May 2026 Mepolizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... View
M5.001.019 Fasenra® (benralizumab) May 2026 Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... View