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 |
|---|---|---|---|---|---|
| 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 |
| P1.001.015 | Xenpozyme | Sep 20, 2023 | Sep 20, 2024 | Xenopozyme may be considered medically necessary in adult and pediatric patients for the treatment of... | View |
| P1.001.016 | Fyarro | Sep 20, 2023 | Sep 20, 2024 | Coverage eligibility for sirolimus protein-bound particles (fyarro) will be considered when the following... | View |
| P1.002.001 | Entyvio® (vedolizumab) | Dec 04, 2023 | 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 04, 2023 | Dec 20, 2024 | Coverage is provided in the following conditions: universal criteria must not be used in... | View |
| P1.002.003 | Somatuline® Depot; Lanreotide | Dec 04, 2023 | Dec 20, 2024 | Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... | View |
| P1.002.004 | Nucala® (mepolizumab) | Dec 04, 2023 | Dec 20, 2024 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | View |
| P1.002.005 | Ocrevus™ (ocrelizumab) | Dec 04, 2023 | Dec 20, 2024 | Coverage is provided in the following conditions: ï· patient is 18 years or older (unless otherwise... | View |
| P1.002.006 | Simponi ARIA® (golimumab) | Dec 04, 2023 | Dec 20, 2024 | Coverage is provided in the following conditions: patient is at least 18 years of age, unless otherwise... | View |
| P1.002.007 | Stelara® (ustekinumab) | Dec 04, 2023 | Dec 20, 2024 | Stelara® (ustekinumab) may be considered medically necessary if the following conditions are met: patient... | View |
| P1.002.008 | Tysabri (natalizumab) | Dec 04, 0202 | Dec 20, 2024 | Initial approval criteria • patient is at least 18 years of age; and universal criteria 1,13 •... | View |
| P1.002.009 | Xolair® (omalizumab) | Dec 04, 2023 | Dec 20, 2024 | Coverage is provided in the following conditions: • patient is at least 18 years of age (unless otherwise... | View |
| P1.002.010 | Ruconest (C1 Esterase Inhibitor [recombinant]) | Feb 19, 2024 | Feb 20, 2025 | Coverage is provided in the following conditions: • patient is at least 13 years of age; and... | View |
| PP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 11, 2023 | May 20, 2024 | I. dose rounding for infused drug products to the nearest lowest vial size if within... | View |
| PP.001.002 | Leuprolide | Aug 29, 2023 | Jul 20, 2024 | Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... | View |
| PP.002.001 | Readmissions Review Quality Program (RRQP) | Mar 01, 2024 | Mar 01, 2025 | Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... | View |
