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 |
|---|---|---|---|---|---|
| M5.001.018 | Nucala® (mepolizumab) | May 14, 2025 | May 20, 2026 | Mepolizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.019 | Fasenra® (benralizumab) | May 14, 2025 | May 20, 2026 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | May 14, 2025 | May 20, 2026 | 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 | May 14, 2025 | May 20, 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | May 14, 2025 | May 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 06, 2025 | Aug 20, 2026 | 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 |
| M5.001.025 | Mitotic Inhibitors | Sep 25, 2025 | Aug 20, 2026 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | 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 | Jul 08, 2025 | May 20, 2026 | ... | 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 |
| P01.001.001 | Adakveo | Jul 08, 2022 | Jul 08, 2023 | Adakveo is a prescription medicine used to treat the symptoms of sickle cell disease. adakveo may be used... | View |
| P01.001.002 | Beovu | Jul 08, 2022 | Jul 08, 2023 | Beovu is a prescription medicine used to treat neovascular (wet) age-related macular degeneration (amd) and... | View |
| P1.001.001 | Adakveo | Sep 17, 2024 | Sep 20, 2025 | Adakveo is a prescription medicine used to treat the symptoms of sickle cell disease. adakveo may be used... | View |
| P1.001.004 | Danyelza | Sep 17, 2024 | Sep 20, 2025 | Danyelza (naxitamab-gqgk) is a gd2-binding monoclonal antibody indicated, in combination with... | View |
| P1.001.005 | Jemperli | Sep 17, 2024 | Sep 20, 2025 | Jemperli is a programmed death receptor-1 (pd-1)–blocking antibody indicated for: endometrial cancer... | View |
| P1.001.006 | Margenza | Sep 17, 2024 | Sep 20, 2025 | Margenza is a her2/neu receptor antagonist indicated, in combination with chemotherapy, for the treatment of... | View |
| P1.001.007 | Monjuvi | Sep 17, 2024 | Sep 20, 2025 | Monjuvi is a cd19-directed cytolytic antibody indicated in combination with lenalidomide for the treatment of... | View |
| P1.001.008 | Rybrevant | Sep 17, 2024 | Sep 20, 2025 | Rybrevant is a bispecific egf receptor-directed and met receptor-directed antibody indicated for the... | View |
