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 |
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M5.001.008 | Simponi ARIA® (golimumab) | Dec 04, 2023 | Dec 20, 2024 | Simponi aria® (golimumab) may be considered medically necessary in patients is at least 18 years of... | View |
M5.001.009 | Stelara® (ustekinumab) | Dec 04, 2023 | Dec 20, 2024 | 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) | Oct 13, 2023 | Dec 20, 2023 | 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 | Dec 04, 2023 | Dec 20, 2024 | 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 Deseases | Dec 04, 2023 | Dec 20, 2024 | Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... | View |
M7.001.001 | Laser Treatment of Wine Stains | Jan 18, 2023 | Policy Archived | Laser treatment of port wine stains in the presence of functional impairment related to the port wine stains... | 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 |
P01.001.002 | Beovu | Jul 08, 2022 | Jul 08, 2023 | Beovu is covered under the medical benefit when used within the following guidelines. use outside of these... | View |
P1.001.001 | Adakveo | Sep 20, 2023 | Sep 20, 2024 | Adakveo may be considered medically necessary in patients 16 years of age or older with vasoocclusive crises... | View |
P1.001.004 | Danyelza | Sep 20, 2023 | Sep 20, 2024 | Initiation of danyelza meets the definition of medical necessity when used to treat the following indication... | View |
P1.001.005 | Jemperli | Sep 20, 2023 | Sep 20, 2024 | Jemperli may be considered medically necessary if the conditions below are... | View |
P1.001.006 | Margenza | Sep 20, 2023 | Sep 20, 2024 | Margenza may be considered medically necessary in patients 18 years of age or older for the treatment of... | View |
P1.001.007 | Monjuvi | Sep 20, 2023 | Sep 20, 2024 | Monjuvi may be considered medically necessary in patients 18 years of age or older for the treatment of adult... | View |
P1.001.008 | Rybrevant | Sep 20, 2022 | Sep 20, 2023 | Rybrevant may be considered medically necessary in patients 18 years of age or older for the treatment of... | View |
P1.001.009 | Elahere (mirvetuximab soravtansine-gynx) | Sep 20, 2023 | Sep 20, 2024 | Initiation of elahere meets the definition of medical necessity when used to treat the following indication... | View |
P1.001.010 | Ublituximab-xiiy (Briumvi) | Sep 20, 2023 | Sep 20, 2024 | Initiation of ublituximab-xiiy (briumvi) meets the definition of medical necessity when all the criteria... | View |
P1.001.011 | Imjudo (tremelimumab-actl) | Sep 20, 2023 | Sep 20, 2024 | Initiation of imjudo meets the definition of medical necessity when used to treat the established indications... | View |
P1.001.012 | Teclistamab (Tecvayli) | Sep 20, 2023 | Sep 20, 2024 | Initiation of teclistamab (tecvayli) meets the definition of medical necessity when all the criteria below... | View |
P1.001.013 | Enjaymo | Sep 20, 2023 | Sep 20, 2024 | Enjaymo may be considered medically necessary in adult patients for the of hemolysis in adults with cold... | View |
P1.001.014 | Opdualag | Sep 20, 2023 | Sep 20, 2024 | Opdualag may be considered medically necessary in patients 12 years of age or older at least 40 kg for the... | View |