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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 |
|---|---|---|---|---|---|
| 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® (crizanlizumab-tmca) | Sep 17, 2024 | Sep 20, 2025 | Adakveo may be considered medically necessary in patients 16 years of age or older with vasoocclusive crises... | View |
| P1.001.004 | DANYELZA® (naxitamab-gqgk) | Sep 17, 2024 | Sep 20, 2025 | Initiation of danyelza meets the definition of medical necessity when used to treat the following indication... | View |
| P1.001.005 | JEMPERLI (dostarlimab-gxly) | Sep 17, 2024 | Sep 20, 2025 | Policy statements jemperli may be considered medically necessary if the conditions below are... | View |
| P1.001.006 | MARGENZA® (margetuximab-cmkb) | Sep 17, 2024 | Sep 20, 2025 | Margenza may be considered medically necessary in patients 18 years of age or older for the treatment of... | View |
| P1.001.007 | MONJUVI® (tafasitamab-cxix) | Sep 17, 2024 | Sep 20, 2025 | Monjuvi may be considered medically necessary in patients 18 years of age or older for the treatment of adult... | View |
| P1.001.008 | RYBREVANT® (amivantamab-vmjw) | Sep 17, 2024 | Sep 20, 2025 | 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 17, 2024 | Sep 20, 2025 | Initiation of elahere meets the definition of medical necessity when used to treat the following indication... | View |
| P1.001.010 | BRIUMVI® (ublituximab-xiiy) | Oct 09, 2024 | Sep 20, 2025 | Initiation of ublituximab-xiiy (briumvi) meets the definition of medical necessity when all the criteria... | View |
| P1.001.011 | IMJUDO® (tremelimumab-actl) | Sep 17, 2024 | Sep 20, 2025 | Initiation of imjudo meets the definition of medical necessity when used to treat the established indications... | View |
| P1.001.012 | TECVAYLI® (teclistamab-cqyv) | Sep 17, 2024 | Sep 20, 2025 | Initiation of teclistamab (tecvayli) meets the definition of medical necessity when all the criteria below... | View |
| P1.001.013 | ENJAYMO® (sutimlimab-jome) | Sep 17, 2024 | Sep 20, 2025 | Enjaymo may be considered medically necessary in adult patients for the of hemolysis in adults with cold... | View |
| P1.001.014 | OPDUALAG™ (nivolumab and relatlimab-rmbw) | Sep 17, 2024 | Sep 20, 2025 | Opdualag may be considered medically necessary in patients 12 years of age or older at least 40 kg for the... | View |
| P1.001.015 | XENPOZYME® (olipudase alfa-rpcp) | Sep 17, 2024 | Sep 20, 2025 | Xenopozyme may be considered medically necessary in adult and pediatric patients for the treatment of... | View |
| P1.001.016 | FYARRO™ (sirolimus protein-bound particles for injectable suspension) | Sep 17, 2024 | Sep 20, 2025 | Coverage eligibility for sirolimus protein-bound particles (fyarro) will be considered when the following... | View |
| P1.002.001 | Entyvio® (vedolizumab) | Dec 16, 2024 | Dec 20, 2024 | Coverage is provided in the following conditions: • patient is at least 18 years of age; and •... | View |
| P1.002.002 | Fasenra® (benralizumab) | Dec 17, 2024 | Dec 20, 2025 | Coverage is provided in the following conditions: universal criteria must not be used in... | View |
| P1.002.003 | Somatuline® Depot; Lanreotide | Dec 17, 2024 | Dec 20, 2025 | Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... | View |
| P1.002.004 | Nucala® (mepolizumab) | Dec 17, 2024 | Dec 20, 2025 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | View |
| P1.002.005 | Ocrevus™ (ocrelizumab) | Dec 17, 2024 | Dec 20, 2025 | Initiation of ocrelizumab (ocrevus) meets the definition of medical necessity when all the criteria below is... | View |
