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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 |
|---|---|---|---|---|---|
| M5.001.009 | Stelara® (ustekinumab) | May 10, 2024 | May 20, 2025 | Stelara® (ustekinumab) may be considered medically necessary if the following conditions are met: patient... | View |
| M5.001.010 | Infliximab (Remicade, Inflectra, Renflexis, Avsola and Unbranded Infliximab) | May 10, 2024 | May 20, 2025 | Infliximab (remicade) is a tumor necrosis factor α (tnf-α) blocking agent approved by the u.s. food and... | View |
| M5.001.011 | Erythropoiesis Stimulating Agents | May 10, 2024 | May 20, 2025 | 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 | May 10, 2024 | May 20, 2025 | Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... | View |
| M5.001.013 | Ruconest (C1 Esterase Inhibitor [recombinant]) | May 10, 2024 | May 20, 2025 | 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 10, 2024 | May 20, 2025 | 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 10, 2024 | May 20, 2025 | Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... | View |
| M5.001.016 | Lumasiran for Primary Hyperoxaluria Type 1 | May 10, 2024 | May 20, 2025 | 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 10, 2024 | May 20, 2025 | The hemophilias are a group of related bleeding disorders that most commonly are inherited. inherited... | View |
| M5.001.018 | Nucala® (mepolizumab) | Jun 25, 2024 | Jun 20, 2025 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | View |
| M5.001.019 | Fasenra® (benralizumab) | Jun 25, 2024 | Jun 20, 2025 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | Jun 25, 2024 | Jun 20, 2025 | Initial treatment givosiran may be considered medically necessary if all of the following conditions are... | View |
| M5.001.021 | Biological Treatments for Refractory Myasthenia Gravis | Jun 25, 2024 | Jun 20, 2025 | Eculizumab and ravulizumab-cwvz - initial treatment eculizumab and ravulizumab-cwvz may be... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | Oct 09, 2024 | Jun 20, 2025 | Coverage is provided in the following conditions: • patient is at least 18 years of age (unless... | View |
| M5.001.023 | Soliris® (eculizumab) | Aug 22, 2024 | Aug 20, 2025 | Coverage is provided in the following conditions: • patient is at least 18 years of age (unless... | View |
| M7.001.001 | Laser Treatment of Wine Stains | May 10, 2024 | Policy Archived | Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... | View |
| MP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 10, 2024 | May 20, 2025 | I. dose rounding for infused drug products to the nearest lowest vial size if within... | View |
| MP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... | View |
| MP.001.003 | Split Surgical Package | Jun 21, 2024 | Jun 20, 2025 | This policy describes reimbursement for components of the global surgical package. the policy applies to... | View |
| P01.001.001 | Adakveo | Jul 08, 2022 | Jul 08, 2023 | Adakveo may be considered medically necessary in patients 16 years of age or older with vasoocclusive crises... | View |
