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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 |
|---|---|---|---|---|---|
| P1.002.006 | Simponi ARIA® (golimumab) | Dec 17, 2024 | Dec 20, 2025 | Coverage is provided in the following conditions: patient is at least 18 years of age, unless otherwise... | View |
| P1.002.007 | Stelara® (ustekinumab) | Dec 17, 2024 | Dec 20, 2025 | Stelara® (ustekinumab) may be considered medically necessary if the following conditions are met: patient... | View |
| P1.002.008 | Tysabri (natalizumab) | Dec 17, 2024 | Dec 20, 2025 | Initial approval criteria • patient is at least 18 years of age; and universal criteria 1,13 •... | View |
| P1.002.009 | Xolair® (omalizumab) | Dec 17, 2024 | Dec 20, 2025 | 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]) | Sep 17, 2024 | Sep 20, 2025 | Coverage is provided in the following conditions: • patient is at least 13 years of age; and... | View |
| P1.002.011 | Ultomiris® (ravulizumab-cwvz) | Oct 24, 2024 | Jun 27, 2025 | Coverage is provided in the following conditions: • patient is at least 18 years of age (unless... | View |
| P1.002.012 | Soliris® (eculizumab) | Sep 17, 2024 | Sep 20, 2025 | Coverage is provided in the following conditions: • patient is at least 18 years of age (unless... | 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... | 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.002.002 | Discontinued Procedures/Reduced Services – Modifiers 73 & 74 | Aug 26, 2024 | Aug 20, 2025 | Payment policy: modifiers 73 and 74 provide a way for hospitals to report and be paid for expenses... | View |
| PP.002.004 | Split Surgical Package | Jun 21, 2024 | Jun 20, 2025 | This policy describes reimbursement for components of the global surgical package. the policy applies to... | View |
