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 |
|---|---|---|---|---|
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | May 2026 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M5.001.023 | Soliris (eculizumab) | Aug 2025 | Soliris is a complement inhibitor indicated for the treatment of patients with paroxysmal nocturnal... | View |
| M5.001.024 | Adstiladrin® (nadofaragene firadenovec-vncg) | Jun 2026 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| M5.001.025 | Mitotic Inhibitors | Sep 2025 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | View |
| M5.001.026 | Botulinum Toxin | Mar 2026 | ... | View |
| 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 |