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 |
|---|---|---|---|---|---|
| P1.001.014 | Opdualag | Sep 17, 2024 | Sep 20, 2025 | Nivolumab;relatlimab-rmbw (opdualag) has been approved for the treatment of adult and pediatric patients 12... | View |
| P1.001.015 | Xenpozyme | Sep 17, 2024 | Sep 20, 2025 | Olipudase alfa (xenpozyme) is an enzyme replacement therapy, for the treatment of non-central nervous system... | View |
| P1.001.016 | Fyarro | Sep 17, 2024 | Sep 20, 2025 | Sirolimus protein-bound particles (fyarro) a mammalian target of rapamycin (mtor) inhibitor, is indicated for... | View |
| P1.002.001 | Vedolizumab | Dec 16, 2024 | Dec 20, 2024 | Vedolizumab is a recombinant human igg1 monoclonal antibody produced in chinese hamster ovaries. it binds to... | View |
| P1.002.002 | Benralizumab | Dec 17, 2024 | Dec 20, 2025 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| P1.002.003 | Somatuline® Depot; Lanreotide | Dec 17, 2024 | Dec 20, 2025 | Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... | View |
| P1.002.004 | Nucala® (mepolizumab) | Dec 17, 2024 | Dec 20, 2025 | Mepolizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| P1.002.005 | Ocrevus™ (ocrelizumab) | Dec 17, 2024 | Dec 20, 2025 | Ocrelizumab is a humanized monoclonal antibody that is directed against cd20-expressing b-cells. cd20 is a... | View |
| P1.002.006 | Simponi ARIA® (golimumab) | Dec 17, 2024 | Dec 20, 2025 | Golimumab is in a class of drugs called biologics. golimumab is a treatment for adults with moderate to... | View |
| P1.002.007 | Stelara® (ustekinumab) | Dec 17, 2024 | Dec 20, 2025 | Stelara is a human igg1κ monoclonal antibody that binds with high affinity and specificity to the p40... | View |
| P1.002.008 | Tysabri® (natalizumab) | Dec 17, 2024 | Dec 20, 2025 | Tysabri® (natalizumab) is a monoclonal antibody produced with recombinant dna technology in murine... | View |
| P1.002.009 | Xolair® (omalizumab) | Dec 17, 2024 | Dec 20, 2025 | Omalizumab is an anti-ige monoclonal antibody produced by recombinant dna technology using chinese hamster... | View |
| P1.002.010 | Ruconest (C1 Esterase Inhibitor [recombinant]) | Sep 17, 2024 | Sep 20, 2025 | C-1 esterase inhibitor protein is one of nine complement proteins found in the blood that works with the... | View |
| P1.002.011 | Ultomiris® (ravulizumab-cwvz) | Jun 23, 2025 | Jun 20, 2026 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| P1.002.012 | Soliris (eculizumab) | Sep 17, 2024 | Sep 20, 2025 | Soliris is a complement inhibitor indicated for the treatment of patients with paroxysmal nocturnal... | View |
| P1.002.013 | Adstiladrin® (nadofaragene firadenovec-vncg) | Feb 20, 2025 | Feb 20, 2026 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| PP.001.001 | Dose Rounding of Drug Covered Under The Medical Benefit | May 14, 2025 | May 20, 2026 | ... | View |
| PP.001.002 | Leuprolide | May 14, 2025 | May 20, 2026 | (leuprolide acetate) – a drug that is a manufactured version of a hormone. it is a hormone-releasing... | View |
| PP.002.002 | Discontinued Procedures/Reduced Services – Modifiers 73 & 74 | Aug 26, 2024 | Aug 20, 2025 | The term "discontinued procedure" designates a surgical or diagnostic procedure provided by a... | View |
| PP.002.004 | Split Surgical Package | Jun 21, 2024 | Jun 20, 2025 | ... | View |
