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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 |
|---|---|---|---|---|---|
| 05.001.023 | Newer Oral Anticoagulants | Jul 27, 2020 | Policy Archived | Nonvalvular atrial fibrillation rivaroxaban* (xarelto®), dabigatran* (pradaxa®), apixaban* (eliquis®),... | View |
| 05.001.024 | Ado-Trastuzumab Emtansine (Trastuzumab-DM1) for Treatment of HER2-Positive Malignancies | Aug 19, 2024 | Aug 20, 2025 | The use of ado-trastuzumab emtansine may be considered medically necessary in individuals with: human... | View |
| 05.001.026 | Pertuzumab for Treatment of Malignancies | Nov 12, 2024 | Nov 20, 2025 | In patients who have human epidermal growth factor receptor 2 (her2)-positive breast cancer, the use of... | View |
| 05.001.028 | Treatment for Spinal Muscular Atrophy | Apr 19, 2024 | Apr 20, 2025 | Nusinersen initial treatment nusinersen may be considered medically necessary if all the following... | View |
| 05.001.029 | Nononcologic Uses of Rituximab | Nov 14, 2024 | Nov 20, 2025 | Rituximab may be considered medically necessary for the following off-label indications:... | View |
| 05.001.030 | Testosterone Replacement Therapies | Aug 13, 2024 | Aug 20, 2025 | Testosterone replacement therapy may be considered medically necessary under the following conditions:... | View |
| 05.001.031 | Treatment for Duchenne Muscular Dystrophy | Sep 24, 2024 | Jun 20, 2025 | The use of antisense oligonucleotides (such as eteplirsen, golodirsen, viltolarsen,and casimersen) is... | View |
| 05.001.032 | Buprenorphine Implant for Treatment of Opioid Dependence | Oct 18, 2022 | Policy Archived | Buprenorphine is a partial μ-opioid agonist used to treat patients with an opioid addiction. administered... | View |
| 05.001.033 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients | Jan 14, 2025 | Jan 20, 2026 | Initial treatment - hereditary transthyretin-mediated amyloidosis polyneuropathy patisiran, vutrisiran,... | View |
| 05.001.034 | Tropomyosin Receptor Kinase Inhibitors for Locally Advanced or Metastatic Solid Tumors Harboring an NTRK Gene Fusion | Apr 19, 2024 | Policy Archived | Larotrectinib and entrectinib are considered medically necessary when all of the following are met:... | View |
| 05.001.035 | Monoclonal Antibody Therapies for Migraine and Cluster Headache | Jan 15, 2025 | Jan 20, 2026 | Subcutaneously administered food and drug administration (fda)-approved monoclonal antibodies for calcitonin... | View |
| 05.001.036 | Brexanolone for Postpartum Depression | Sep 10, 2024 | Sep 20, 2025 | Individuals may be considered for a 1 time use of brexanolone per pregnancy if they meet all of the following... | View |
| 05.001.037 | Medical Cannabis for the Treatment of Pain and Spasticity | Sep 07, 2023 | Policy Archived | Inhaled cannabis or extracted cannabinoids are considered investigational for the treatment of the... | View |
| 05.001.038 | Erythropoiesis-Stimulating Agents | Nov 11, 2024 | Nov 20, 2025 | The use of epoetin alfa, darbepoetin, or pegylated epoetin beta may be considered medically necessary for:... | View |
| 05.001.039 | Intravenous Antibiotic Therapy and Associated Diagnostic Testing for Lyme Disease | Nov 22, 2024 | Nov 20, 2025 | Lyme disease treatment of lyme disease consists of oral antibiotics, except for the following indications.... | View |
| 05.001.040 | Repository Corticotropin Injection | Nov 22, 2024 | Nov 20, 2025 | Repository corticotropin injection may be considered medically necessary for the treatment of infantile... | View |
| 05.001.041 | Injectable Clostridial Collagenase for Fibroproliferative Disorders | Apr 17, 2024 | Apr 20, 2025 | Injectable clostridial collagenase for the treatment of dupuytren's contracture in adults with a palpable... | View |
| 05.001.042 | Esketamine Nasal Spray for Treatment-Resistant Depression | Nov 12, 2024 | Nov 20, 2025 | Treatment-resistant depression esketamine nasal spray may be considered medically necessary if all of... | View |
| 05.001.043 | Hematopoietic Colony-Stimulating Factors (CSFs) | Oct 24, 2024 | Oct 20, 2025 | Trple s considers short-acting granulocyte colony stimulating factors (g-csfs), medically necessary for... | View |
| 05.001.044 | Polivy® (polatuzumab vedotin-piiq) | Oct 24, 2024 | Oct 20, 2025 | Polatuzumab vedotin-piiq (polivy) is considered medically necessary for the treatment of adult patients with... | View |
