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 |
|---|---|---|---|---|---|
| P1.002.010 | 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 10, 2024 | May 20, 2025 | I. dose rounding for infused drug products to the nearest lowest vial size if within +/- 10% of... | View |
| PP.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 |
| PP.002.001 | Readmissions Review Quality Program (RRQP) | Apr 24, 2024 | Retired | Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... | View |
