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
13.010.001 Orthodontic Services Oct 2024 The branch of dentistry that is responsible for the study, prevention, diagnosis and treatment of anomalies... View
7.001.168 Surgical Left Atrial Appendage Occlusion Devices for Stroke Prevention in Atrial Fibrillation Sep 2022 Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... View
99.001.001 Gene Therapies for Duchenne Muscular Dystrophy Apr 2026 Duchenne muscular dystrophy (dmd) is an inherited disorder that results in progressive muscle weakness and... View
99.999.999 List of Retired Policies Sep 2026 List of retired... View
M3.001.001 Therapeutic Radiopharmaceuticals for Prostate Cancer Aug 2026 ... View
M5.001.001 Viscosupplementation Therapy For Knee May 2026 Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... View
M5.001.002 Rituximab May 2026 Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... View
M5.001.003 Trastuzumab – Trastuzumab Biologics Aug 2026 Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... View
M5.001.005 Bevacizumab Aug 2026 Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... View
M5.001.006 G-Csf Filgrastim Aug 2026 White blood cell growth factors, also known as granulocyte colony stimulating factors (g-csf), are... View
M5.001.007 Somatuline® Depot; Lanreotide May 2026 Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... View
M5.001.008 Simponi ARIA® (golimumab) May 2026 Golimumab is in a class of drugs called biologics. golimumab is a treatment for adults with moderate to... View
M5.001.009 Stelara® (ustekinumab) May 2026 Stelara is a human igg1κ monoclonal antibody that binds with high affinity and specificity to the p40... View
M5.001.010 Infliximab Aug 2026 Infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent approved by the... View
M5.001.011 Erythropoiesis Stimulating Agents May 2026 Endogenous erythropoietin is a glycoprotein hematopoietic growth factor that regulates hemoglobin levels in... View
M5.001.012 Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases Aug 2026 Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... View
M5.001.013 Ruconest May 2026 C-1 esterase inhibitor protein is one of nine complement proteins found in the blood that works with the... View
M5.001.014 Immune Globulin May 2026 Immune globulin (also referred to as gamma globulin or immunoglobulin) is a therapeutic compound prepared... View
M5.001.015 Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients Jul 2026 Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... View
M5.001.016 Lumasiran for Primary Hyperoxaluria Type 1 May 2026 Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... View