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 |
|---|---|---|---|---|---|
| 05.001.043 | Hematopoietic Colony-Stimulating Factors (Csfs) | Sep 25, 2025 | Sep 20, 2026 | Hematopoietic colony-stimulating factors (csfs) are biologic agents used to stimulate the production of... | View |
| 05.001.044 | Polivy® (polatuzumab vedotin-piiq) | Sep 25, 2025 | Sep 20, 2026 | Polivy® (polatuzumab vedotin-piiq) is an antibody-drug conjugate directed against cd79b. it is... | View |
| 05.001.045 | Lumasiran For Primary Hyperoxaluria Type 1 | Aug 09, 2025 | Aug 20, 2026 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
| 05.001.046 | Monoclonal Antibodies for Treatment of Alzheimer Disease | Aug 27, 2024 | Policy Archived | Alzheimer disease (ad) is a neurodegenerative disorder leading to progressive, irreversible destruction of... | View |
| 05.001.047 | Fibrin Sealant | Sep 25, 2025 | Policy Archived | ... | View |
| 05.001.048 | Biological Treatments for Refractory Myasthenia Gravis | Jul 11, 2025 | Jul 20, 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| 05.001.049 | Givosiran for Acute Hepatic Porphyria | Oct 17, 2025 | Oct 20, 2026 | Acute hepatic porphyria (ahp) is a rare disease with a prevalence of 5 to 10 cases/100,000 people in the us... | View |
| 05.001.050 | Omidubicel as Adjunct Treatment for Hematologic Malignancies | Oct 08, 2025 | Oct 20, 2026 | Hematologic malignancies are a heterogeneous group of diseases characterized by distinct biological subtypes,... | View |
| 05.001.051 | Pharmacologic Treatments for Metabolic Dysfunction-Associated Steatohepatitis | Nov 13, 2025 | Nov 20, 2026 | Metabolic dysfunction-associated steatohepatitis (mash), formerly known as non-alcoholic steatohepatitis... | View |
| 05.001.052 | Tofersen (Qalsody) | Sep 25, 2025 | Sep 20, 2026 | Tofersen (qalsody) is an antisense oligonucleotide indicated for the treatment of amyotrophic lateral... | View |
| 05.001.053 | Mitotic Inhibitors | Sep 25, 2025 | Sep 20, 2026 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | View |
| 05.001.054 | Denosumab Products and its biosimilars | Jan 14, 2026 | Jan 20, 2027 | Denosumab is a fully human monoclonal antibody against receptor activator of nuclear factor κ-β... | View |
| 05.002.001 | Chimeric Antigen Receptor Therapy For Multiple Myeloma | Aug 12, 2025 | Aug 20, 2026 | Multiple myeloma is a hematologic malignancy characterized by abnormal growth of plasma cells with production... | View |
| 05.003.001 | Gene Therapies for Thalassemia | Apr 21, 2025 | Apr 20, 2026 | Beta (β)-thalassemia is a genetic hemoglobinopathy that results from defects in β-globin synthesis... | View |
| 05.003.002 | Gene Therapies for Sickle Cell Disease | Apr 22, 2025 | Apr 20, 2026 | Sickle cell disease is a genetic hemoglobinopathy that results from a genetic variant in the hbb gene... | View |
| 05.003.003 | Gene Therapies for Metachromatic Leukodystrophy | Jul 15, 2025 | Jul 20, 2026 | Metachromatic leukodystrophy (mld) is a rare autosomal recessive lysosomal storage disorder. it arises due to... | View |
| 05.003.004 | Gene Therapies for Duchenne Muscular Dystrophy | Dec 31, 1969 | Oct 20, 2026 | Duchenne muscular dystrophy (dmd) is an inherited disorder that results in progressive muscle weakness and... | View |
| 05.003.005 | Gene Therapies for Congenital Hemophilia A or B | Oct 17, 2025 | Oct 20, 2026 | Most commonly, hemophilia is a recessive x-linked congenital bleeding disorder that predominantly affects... | View |
| 05.003.006 | Gene Therapies for Cerebral Adrenoleukodystrophy | Jan 23, 2026 | Dec 20, 2026 | Cerebral adrenoleukodystrophy (cald) is an x-linked genetic neurodegenerative disease that most severely... | View |
| 05.003.007 | Gene Therapies for Aromatic L-amino Acid Decarboxylase Deficiency | Sep 22, 2025 | Sep 20, 2026 | Aromatic l-amino acid decarboxylase (aadc) deficiency is a rare autosomal recessive neurodevelopmental... | View |
