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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 |
|---|---|---|---|---|---|
| 05.001.024 | Ado-Trastuzumab Emtansine (Trastuzumab-Dm1) For Treatment Of Her2-Positive Malignancies | Aug 19, 2024 | Aug 20, 2025 | Ado-trastuzumab emtansine, also known as trastuzumab-dm1 (t-dm1), is an antibody-drug conjugate that links... | View |
| 05.001.026 | Pertuzumab For Treatment Of Malignancies | Nov 12, 2024 | Nov 20, 2025 | Pertuzumab (perjeta), a monoclonal antibody, is a human epidermal growth factor receptor 2 (her2) antagonist.... | View |
| 05.001.028 | Treatment For Spinal Muscular Atrophy | Apr 19, 2024 | Apr 20, 2025 | Spinal muscular atrophy is an inherited disorder caused by homozygous deletions or variants in the smn1 gene.... | View |
| 05.001.029 | Nononcologic Uses Of Rituximab | Nov 14, 2024 | Nov 20, 2025 | ... | View |
| 05.001.030 | Testosterone Replacement Therapies | Aug 13, 2024 | Aug 20, 2025 | Testosterone replacement therapy is the primary treatment for androgen deficiency in men. testosterone... | View |
| 05.001.031 | Treatment For Duchenne Muscular Dystrophy | Sep 24, 2024 | Jun 20, 2025 | Duchenne muscular dystrophy is an inherited disorder that results in progressive muscle weakness and loss of... | 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 | Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... | 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 | The tropomyosin receptor kinase (trk)-receptor family is encoded by the 3 neurotrophic receptor tyrosine... | View |
| 05.001.035 | Monoclonal Antibody Therapies For Migraine and Cluster Headache | Jan 15, 2025 | Jan 20, 2026 | Migraine is a headache disorder characterized by recurrent moderate to severe headaches with associated... | View |
| 05.001.036 | Brexanolone For Postpartum Depression | Sep 10, 2024 | Sep 20, 2025 | Postpartum depression (ppd) is a serious and debilitating condition that is characterized by a major... | View |
| 05.001.037 | Medical Cannabis For The Treatment Of Pain And Spasticity | Sep 07, 2023 | Policy Archived | Cannabis describes organic products (eg, cannabinoids, marijuana, hemp) that are derived from the cannabis... | View |
| 05.001.038 | Erythropoiesis-Stimulating Agents | Nov 11, 2024 | Nov 20, 2025 | Endogenous erythropoietin is a glycoprotein hematopoietic growth factor that regulates hemoglobin levels in... | View |
| 05.001.039 | Intravenous Antibiotic Therapy And Associated Diagnostic Testing For Lyme Disease | Nov 22, 2024 | Nov 20, 2025 | Lyme disease is a multisystem inflammatory disease caused by the spirochete borrelia burgdorferi and... | View |
| 05.001.040 | Repository Corticotropin Injection | Nov 22, 2024 | Nov 20, 2025 | Repository corticotropin injection is a preparation of the natural form of adrenocorticotropic hormone... | View |
| 05.001.041 | Injectable Clostridial Collagenase For Fibroproliferative Disorders | Apr 17, 2024 | Apr 20, 2025 | Clostridial collagenase is a bacterial collagenase, derived from clostridium histolyticum, which has been... | View |
| 05.001.042 | Esketamine Nasal Spray For Treatment-Resistant Depression | Nov 12, 2024 | Nov 20, 2025 | Esketamine is the s-isomer of racemic ketamine. esketamine targets the n-methyl-d-aspartate receptor, an... | View |
| 05.001.043 | Hematopoietic Colony-Stimulating Factors (Csfs) | Oct 24, 2024 | Oct 20, 2025 | There are several brands of short-acting colony stimulating factor (csf) products on the market, including... | View |
| 05.001.044 | (Polatuzumab Vedotin-Piiq) Polivy | Oct 24, 2024 | Oct 20, 2025 | Polivy is a cd79b-directed antibody–drug conjugate indicated in combination with bendamustine and a... | View |
| 05.001.045 | Lumasiran For Primary Hyperoxaluria Type 1 | Aug 09, 2024 | Aug 20, 2025 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
