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 |
|---|---|---|---|---|---|
| M5.001.022 | 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 22, 2024 | Aug 20, 2025 | 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 |
| 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 | May 10, 2024 | May 20, 2025 | ... | 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 |
| P1.001.009 | Elahere (mirvetuximab soravtansine-gynx) | Sep 17, 2024 | Sep 20, 2025 | Elahere is a folate receptor alpha (frα)-directed antibody and microtubule inhibitor conjugate... | View |
| P1.001.010 | Ublituximab-xiiy (Briumvi) | Oct 09, 2024 | Sep 20, 2025 | Ublituximab-xiiy is monoclonal antibody that is used to reduce the frequency of relapses and delay the... | View |
| P1.001.011 | Imjudo (tremelimumab-actl) injection | Sep 17, 2024 | Sep 20, 2025 | Imjudo is a cytotoxic t-lymphocyte-associated antigen 4 (ctla-4) blocking antibody indicated: in combination... | View |
| P1.001.012 | Teclistamab (Tecvayli) | Sep 17, 2024 | Sep 20, 2025 | Teclistamab (tecvayli) is a bispecific b-cell maturation antigen (bcma)-directed cd3 t-cell engaging antibody... | View |
| P1.001.013 | Enjaymo | Sep 17, 2024 | Sep 20, 2025 | Sutimlimab-jome (enjaymo) is a monoclonal antibody that inhibits the classical complement pathway by binding... | View |
