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 |
|---|---|---|---|---|
| 05.001.012 | (Trastuzumab) Herceptin | Sep 2025 | In certain cancers, the human epidermal growth factor receptor 2 (her2) gene is amplified and overexpressed.... | View |
| 05.001.014 | Intravenous Anesthetics For The Treatment Of Chronic Pain And Psychiatric Disorders | Dec 2025 | Intravenous (iv) infusion of lidocaine or ketamine has been investigated for the treatment of migraine and... | View |
| 05.001.015 | Advanced Therapies For Pharmacologic Treatment Of Pulmonary Hypertension | Dec 2025 | Pulmonary hypertension (ph) is a chronic, progressive condition characterized by abnormally high pulmonary... | View |
| 05.001.016 | Uses Of Monoclonal Antibodies For The Treatment Of Non-Hodgkin Lymphoma | Dec 2024 | Monoclonal antibodies targeted to cancer-associated antigens have been approved by the u.s. food and drug... | View |
| 05.001.017 | Bevacizumab | Dec 2025 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| 05.001.019 | ABATACEPT (ORENCIA) | Dec 1969 | From the decade of 1990 the advances in molecular biology have shown new approaches to the treatment for... | View |
| 05.001.021 | Vandetanib | Oct 2024 | The medication vandetanib is an inhibitor of the "tyrosine kinase" which is selectively targeted to... | View |
| 05.001.023 | Newer Oral Anticoagulants | Jul 2020 | ... | View |
| 05.001.024 | Ado-Trastuzumab Emtansine (Trastuzumab-Dm1) For Treatment Of Her2-Positive Malignancies | Aug 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 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 2026 | 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 2025 | ... | View |
| 05.001.030 | Testosterone Replacement Therapies | Jan 2026 | Testosterone replacement therapy is the primary treatment for androgen deficiency in men. testosterone... | View |
| 05.001.031 | Treatment For Duchenne Muscular Dystrophy | Feb 2026 | 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 2025 | 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 | Jul 2025 | 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 2024 | 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 2026 | Migraine is a headache disorder characterized by recurrent moderate to severe headaches with associated... | View |
| 05.001.036 | Brexanolone For Postpartum Depression | Sep 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 2023 | Cannabis describes organic products (eg, cannabinoids, marijuana, hemp) that are derived from the cannabis... | View |