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 |
|---|---|---|---|---|
| 05.001.038 | Erythropoiesis-Stimulating Agents | Nov 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 2025 | Lyme disease is a multisystem inflammatory disease caused by the spirochete borrelia burgdorferi and... | View |
| 05.001.040 | Repository Corticotropin Injection | Nov 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 2026 | Clostridial collagenase is a bacterial collagenase, derived from clostridium histolyticum, which has been... | View |
| 05.001.042 | Esketamine Nasal Spray For Treatment-Resistant Depression | Jan 2026 | 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) | Sep 2025 | Hematopoietic colony-stimulating factors (csfs) are biologic agents used to stimulate the production of... | View |
| 05.001.044 | Polivy® (polatuzumab vedotin-piiq) | Sep 2025 | 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 2025 | 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 | Mar 2026 | Alzheimer disease (ad) is a neurodegenerative disorder leading to progressive, irreversible destruction of... | View |
| 05.001.047 | Fibrin Sealant | Sep 2025 | ... | View |
| 05.001.048 | Biological Treatments for Refractory Myasthenia Gravis | Mar 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| 05.001.049 | Givosiran for Acute Hepatic Porphyria | Oct 2025 | 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 2025 | 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 2025 | Metabolic dysfunction-associated steatohepatitis (mash), formerly known as non-alcoholic steatohepatitis... | View |
| 05.001.052 | Tofersen (Qalsody) | Sep 2025 | Tofersen (qalsody) is an antisense oligonucleotide indicated for the treatment of amyotrophic lateral... | View |
| 05.001.053 | Mitotic Inhibitors | Sep 2025 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | View |
| 05.001.054 | Denosumab Products and its biosimilars | May 2026 | 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 | Mar 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 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 2026 | Sickle cell disease is a genetic hemoglobinopathy that results from a genetic variant in the hbb gene... | View |