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.
Medical Policies table
| ID | Title | Review | Description | Access |
|---|---|---|---|---|
| M5.001.010 | Infliximab | Aug 2026 | Infliximab (remicade®) is a tumor necrosis factor α (tnf-α) blocking agent approved by the... | View |
| M5.001.011 | Erythropoiesis Stimulating Agents | May 2026 | Endogenous erythropoietin is a glycoprotein hematopoietic growth factor that regulates hemoglobin levels in... | View |
| M5.001.012 | Vascular Endothelial Growth Factor Inhibitors for the Treatment of Ophthalmological Diseases | Aug 2026 | Vascular endothelial growth factor has been implicated in the pathogenesis of a variety of ocular vascular... | View |
| M5.001.013 | Ruconest | May 2026 | C-1 esterase inhibitor protein is one of nine complement proteins found in the blood that works with the... | View |
| M5.001.014 | Immune Globulin | May 2026 | Immune globulin (also referred to as gamma globulin or immunoglobulin) is a therapeutic compound prepared... | View |
| M5.001.015 | Treatment of Hereditary Transthyretin-Mediated Amyloidosis in Adult Patients | Jul 2026 | Hereditary transthyretin-mediated amyloidosis (hattr) is a rare, progressive, and fatal autosomal dominant... | View |
| M5.001.016 | Lumasiran for Primary Hyperoxaluria Type 1 | May 2026 | Primary hyperoxalurias are a group of rare genetic diseases. there are 3 subtypes each resulting in the... | View |
| M5.001.017 | Hemophilia Antihemophilic Factor | May 2026 | The hemophilias are a group of related bleeding disorders that most commonly are inherited. inherited... | View |
| M5.001.018 | Nucala® (mepolizumab) | May 2026 | Mepolizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.019 | Fasenra® (benralizumab) | May 2026 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| M5.001.020 | Givosiran for Acute Hepatic Porphyria | May 2026 | Acute hepatic porphyria (ahp) is a rare disease with a prevalence of 5 to 10 cases/100,000 people in the us... | View |
| M5.001.021 | Biological Treatments for Refractory Myasthenia Gravis | Jul 2026 | Myasthenia gravis is an autoimmune neuromuscular disorder characterized by fluctuating motor weakness... | View |
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | May 2026 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M5.001.023 | Eculizumab Products [eculizumab (Soliris®), eculizumab-aagh(Epysqli), eculizumab-aeeb (Bkemv)] Injection | Aug 2026 | Eculizumab is a terminal complement (c5) inhibitor. this medical drug criteria applies to the reference... | View |
| M5.001.024 | Adstiladrin® (nadofaragene firadenovec-vncg) | Jun 2026 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| M5.001.025 | Mitotic Inhibitors | Aug 2026 | Mitotic inhibitors (paclitaxel, docetaxel, abraxane) are chemotherapy agents used in multiple solid tumors,... | View |
| M5.001.026 | Botulinum Toxin | Mar 2026 | ... | View |
| M5.001.028 | Denosumab Products and its biosimilars | Aug 2026 | Denosumab is a fully human monoclonal antibody against receptor activator of nuclear factor κ-β... | View |
| M5.001.029 | Foscarbidopa-Foslevodopa (Vyalev) | May 2026 | Parkinson’s disease is a progressive neurodegenerative condition caused by a loss of dopaminergic... | View |
| M7.001.001 | Laser Treatment of Wine Stains | May 2024 | Studies have generally found that laser treatment can be effective at lightening port wine stains. the... | View |