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
P1.002.010 Ruconest (C1 Esterase Inhibitor [recombinant]) Sep 2026 Ruconest is a recombinant c1 esterase inhibitor indicated for the treatment of acute attacks of hereditary... View
P1.002.011 Ultomiris® (ravulizumab-cwvz) Jun 2026 Ravulizumab-cwvz (ultomiris™) is a humanized monoclonal antibody with a high affinity for c5, a protein... View
P1.002.012 Eculizumab Products [eculizumab (Soliris®), eculizumab-aagh(Epysqli), eculizumab-aeeb (Bkemv)] Injection Sep 2026 Eculizumab is a terminal complement (c5) inhibitor. this medical drug criteria applies to the reference... View
P1.002.013 Adstiladrin® (nadofaragene firadenovec-vncg) Feb 2026 Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... View
P1.002.014 AMTAGVI (Lifileucel) Sep 2026 Melanoma accounts for less than 2% of all skin cancers as well as all cancer deaths in the united states.... View
P1.002.015 AUCATZYL (Obecabtagene autoleucel) Sep 2026 Aucatzyl is a cd19-directed genetically modified autologous t cell immunotherapy indicated for the treatment... View
P1.002.016 ENCELTO (Revakinagene taroretcel-lwey) Sep 2026 Macular telangiectasia is a progressive ocular disease with two forms, type 1 (mactel1) and type 2 (mactel2).... View
P1.002.017 KEBILIDI (Eladocagene exuparvovec-tneq) Sep 2026 ... View
P1.002.018 LANTIDRA (Donislecel) Sep 2026 Lantidra (donislecel-jujn) is an allogeneic pancreatic islet cell therapy approved by the fda in june 2023.... View
P1.002.019 LAVIV  (Azficel-T) Sep 2026 Azficel-t is an autologous cellular product composed of fibroblasts indicated for improvement of the... View
P1.002.021 OMISIRGE (Omidubicel-onlv) Sep 2026 Omisirge (omidubicel-onlv) is an ex-vivo expanded cell therapy derived from umbilical cord blood, engineered... View
P1.002.022 RETHYMIC (Allogeneic processed thymus tissue – agdc) Sep 2026 ... View
P1.002.023 RYONCIL (Remestemcel-L-rknd) Sep 2026 Remestemcel-l-rknd (ryoncil) is fda-approved for the treatment of steroid-refractory acute graft-versushost... View
P1.002.026 TECELRA  (Afamitresgene autoleucel) Sep 2026 Tecelra (afamitresgene autoleucel) is a melanoma-associated antigen a4 (magea4)-directed genetically modified... View
P1.002.027 ZEVASKYN  (Prademagene zamikeracel) Sep 2026 [dystrophic epidermolysis bullosa (deb) is caused by mutations in the collagen type vii alpha 1 chain... View
P1.002.028 AXTLE (pemetrxed) Sep 2026 Pemetrexed (alimta) was initially approved by the u.s. food and drug administration (fda) in february 2004... View
P1.002.033 Gefitinib Sep 2026 Iressa (gefitinib) is a tyrosine kinase inhibitor indicated for metastatic non-small cell lung cancer (nsclc)... View
PP.001.001 Dose Rounding of Drug Covered Under The Medical Benefit May 2026 ... View
PP.001.002 Leuprolide May 2026 (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... View
PP.001.004 Coverage Guideline for Orphan Drugs and Off-Label and Labeled Use of FDA Approved Drugs Jan 2026 Triple s salud has a procedure designed to ensure the evaluation of requests for coverage of covered... View