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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 |
|---|---|---|---|---|---|
| M5.001.019 | Fasenra® (benralizumab) | May 30, 2024 | May 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 01, 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 27, 2024 | Jun 20, 2025 | Eculizumab and ravulizumab-cwvz - initial treatment eculizumab and ravulizumab-cwvz may be... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | Jun 27, 2024 | Jun 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 +/- 10% of the original... | 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 |
| 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 |
