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 |
|---|---|---|---|---|---|
| 05.001.015 | Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension | Dec 20, 2023 | Dec 20, 2024 | Pulmonary arterial hypertension (pah) combination therapy for the treatment of pah (world health... | View |
| 05.001.016 | Uses of Monoclonal Antibodies for the Treatment of Non-Hodgkin Lymphoma | Nov 08, 2023 | Nov 20, 2024 | Intravenous rituximab intravenous rituximab (rituxan) may be considered medically necessary to treat... | View |
| 05.001.017 | Bevacizumab | Oct 26, 2023 | Oct 20, 2024 | The use of bevacizumab is considered medically necessary for the following conditions: i. fda-approved... | View |
| 05.001.019 | ABATACEPT (ORENCIA) | Oct 26, 2023 | Oct 20, 2024 | Abatacept is considered for payment in the following indications: adults with rheumatoid arthritis (ra)... | View |
| 05.001.021 | Vandetanib) – Oral Chemotheray | Oct 26, 2024 | Oct 20, 2024 | A. vandetanib is considered medically indicated in the treatment of metastatic or unresectable locally... | View |
| 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 09, 2023 | Aug 20, 2024 | 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 08, 2023 | Nov 20, 2024 | 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 09, 2023 | Nov 20, 2024 | Rituximab may be considered medically necessary for the following off-label indications:... | View |
| 05.001.030 | Testosterone Replacement Therapies | Aug 07, 2023 | Aug 20, 2024 | Testosterone replacement therapy may be considered medically necessary under the following conditions:... | View |
| 05.001.031 | Treatment for Duchenne Muscular Dystrophy | Jun 05, 2023 | Jun 20, 2024 | 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 subdermal implants may be considered medically necessary when all four of the following... | View |
| 05.001.033 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients | Apr 15, 2024 | Jan 20, 2025 | Initial treatment - hereditary transthyretin-mediated amyloidosis polyneuropathy patisiran, inotersen,... | 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 08, 2024 | Jan 20, 2025 | Subcutaneously administered food and drug administration (fda)-approved monoclonal antibodies for calcitonin... | View |
| 05.001.036 | Brexanolone for Postpartum Depression | Sep 05, 2023 | Sep 20, 2024 | 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 10, 2023 | Nov 20, 2024 | 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 15, 2023 | Nov 20, 2024 | Lyme disease treatment of lyme disease consists of oral antibiotics, except for the following indications.... | View |
