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.
| ID | Title | Last Review | Next Review | Description | Access |
|---|---|---|---|---|---|
| 13.010.001 | Orthodontic Services | Oct 24, 2024 | Policy Archived | 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 07, 2022 | Sep 07, 2023 | Atrial fibrillation (af) is the most common type of cardiac arrhythmia. stroke associated with af is... | View |
| M3.001.001 | Therapeutic Radiopharmaceuticals for Prostate Cancer | Aug 19, 2025 | Aug 20, 2026 | ... | View |
| M3.001.002 | Radio 223 Injection (Xofigo) | May 06, 2025 | May 20, 2026 | Approximately 240,000 men in the united states are expected to be diagnosed with prostate cancer in 2016.... | View |
| M5.001.001 | Viscosupplementation Therapy For Knee | May 14, 2025 | May 20, 2026 | Viscosupplementation therapy is part of the therapy used in the treatment of osteoarthritis of the knee.... | View |
| M5.001.002 | Rituximab | May 14, 2025 | May 20, 2026 | Rituximab is a genetically engineered chimeric murine/human monoclonal igg1 kappa antibody directed against... | View |
| M5.001.003 | Trastuzumab – Trastuzumab Biologics | Sep 25, 2025 | Sep 20, 2026 | Trastuzumab is a monoclonal antibody, one of a group of drugs designed to attack specific cancer cells.... | View |
| M5.001.005 | Bevacizumab | Sep 25, 2025 | May 20, 2026 | Bevacizumab is a humanized monoclonal antibody directed against vascular endothelial growth factor a... | View |
| M5.001.006 | G-Csf Filgrastim | Sep 25, 2025 | May 20, 2026 | White blood cell growth factors, also known as granulocyte colony stimulating factors (g-csf), are... | View |
| M5.001.007 | Somatuline® Depot; Lanreotide | May 14, 2025 | May 20, 2026 | Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... | View |
| M5.001.008 | Simponi ARIA® (golimumab) | May 14, 2025 | May 20, 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 14, 2025 | May 20, 2026 | Stelara is a human igg1κ monoclonal antibody that binds with high affinity and specificity to the p40... | View |
| M5.001.010 | Infliximab | Sep 25, 2025 | May 20, 2026 | Infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent approved by the... | View |
| M5.001.011 | Erythropoiesis Stimulating Agents | Sep 22, 2025 | May 20, 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 | Sep 25, 2025 | Sep 20, 2026 | Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... | View |
| M5.001.013 | Ruconest | May 14, 2025 | May 20, 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 14, 2025 | May 20, 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 | May 14, 2025 | May 20, 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 14, 2025 | May 20, 2026 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
| M5.001.017 | Hemophilia Antihemophilic Factor | May 14, 2025 | May 20, 2026 | The hemophilias are a group of related bleeding disorders that most commonly are inherited. inherited... | View |
