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 |
|---|---|---|---|---|
| M5.001.028 | Denosumab Products and its biosimilars | May 2026 | Denosumab is a fully human monoclonal antibody against receptor activator of nuclear factor κ-β... | View |
| M5.001.029 | Foscarbidopa-Foslevodopa (Vyalev) | May 2026 | Parkinson’s disease is a progressive neurodegenerative condition caused by a loss of dopaminergic... | View |
| MP.001.001 | Dose rounding of drugs covered under the Medical Benefit | May 2026 | ... | View |
| P1.001.001 | Adakveo | Sep 2026 | Adakveo® is an iv p-selectin inhibitor approved by the fda for reducing vaso-occlusive crises (voc) in... | View |
| P1.001.004 | Danyelza | Sep 2026 | Neuroblastoma is the most common extracranial solid tumor in childhood with 90% of cases diagnosed at younger... | View |
| P1.001.005 | Jemperli | Sep 2026 | Dostarlimab-gxly (jemperli) is a monoclonal antibody that works by targeting the programmed death-1 receptor... | View |
| P1.001.006 | Margenza | Sep 2026 | Margetuximab-cmkb (margenza™) was approved by the u.s. food and drug administration (fda) in december... | View |
| P1.001.007 | Monjuvi | Sep 2026 | Monjuvi (tafasitamab-cxix) is a cd19-directed cytolytic antibody indicated, in combination with lenalidomide,... | View |
| P1.001.008 | Rybrevant | Sep 2026 | Amivantamab-vmjw (rybrevant), a bispecific epidermal growth factor receptor (egfr) and met receptordirected... | View |
| P1.001.009 | Elahere (mirvetuximab soravtansine-gynx) | Sep 2026 | Elahere (mirvetuximab soravtansine-gynx) is a folate receptor alpha (frα)-directed antibody–drug... | View |
| P1.001.010 | Ublituximab-xiiy (Briumvi) | Sep 2026 | Multiple sclerosis (ms) is a chronic disease affecting the central nervous system (cns). it is characterized... | View |
| P1.001.011 | Imjudo (tremelimumab-actl) injection | Sep 2026 | Imjudo is indicated for the treatment of unresectable hepatocellular carcinoma (uhcc) and metastatic... | View |
| P1.001.012 | Teclistamab (Tecvayli) | Sep 2026 | ... | View |
| P1.001.013 | Enjaymo | Sep 2026 | Sutimlimab-jome (enjaymo) is a monoclonal antibody that inhibits the classical complement pathway by binding... | View |
| P1.001.014 | Opdualag | Sep 2026 | Nivolumab is a monoclonal antibody that enhances the antitumor immune response by binding to the programmed... | View |
| P1.001.015 | Xenpozyme | Sep 2026 | ... | View |
| P1.001.016 | Fyarro | Sep 2026 | Fyarro™ (nab-sirolimus) is an mtor inhibitor formulated as sirolimus protein-bound particles... | View |
| P1.002.002 | Benralizumab | Apr 2026 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| P1.002.003 | Somatuline® Depot; Lanreotide | Apr 2026 | Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... | View |
| P1.002.005 | Ocrevus™ (ocrelizumab) | Apr 2026 | Ocrelizumab is a humanized monoclonal antibody that is directed against cd20-expressing b-cells. cd20 is a... | View |