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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
M5.001.008 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
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