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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 is a human igg1κ monoclonal antibody that binds with high affinity and specificity to the p40... | View |
| M5.001.010 | Infliximab | May 10, 2024 | May 20, 2025 | Description- intro infliximab (remicade) is a tumor necrosis factor α (tnf-α) blocking agent... | 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 | 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 | Mepolizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.019 | Fasenra® (benralizumab) | Jun 25, 2024 | Jun 20, 2025 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | Jun 25, 2024 | Jun 20, 2025 | Acute hepatic porphyria (ahp) is a rare disease with a prevalence of 5 to 10 cases/100,000 people in the us... | View |
| M5.001.021 | Biological Treatments for Refractory Myasthenia Gravis | Jun 25, 2024 | Jun 20, 2025 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | Oct 09, 2024 | Jun 20, 2025 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M5.001.023 | Soliris (eculizumab) | Aug 22, 2024 | Aug 20, 2025 | Soliris is a complement inhibitor indicated for the treatment of patients with paroxysmal nocturnal... | View |
| M5.001.024 | Adstiladrin® (nadofaragene firadenovec-vncg) | Feb 20, 2025 | Oct 20, 2025 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| M7.001.001 | May 10, 2024 | Policy Archived | Studies have generally found that laser treatment can be effective at lightening port wine stains. the... | View | |
| MP.001.001 | Dose rounding of drugs covered under the Medical Benefit | May 10, 2024 | May 20, 2025 | ... | View |
| MP.001.002 | Leuprolide | May 10, 2024 | May 20, 2025 | (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... | View |
| MP.001.003 | Split Surgical Package | Jun 21, 2024 | Jun 20, 2025 | ... | View |
