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 |
|---|---|---|---|---|---|
| P1.002.013 | 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 |
| P1.002.014 | AMTAGVI (Lifileucel) | Sep 22, 2025 | Sep 20, 2026 | Amtagvi (lifileucel) is an autologous til (tumor-infiltrating lymphocyte) therapy approved by the fda in... | View |
| P1.002.015 | AUCATZYL (Obecabtagene autoleucel) | Sep 22, 2025 | Sep 20, 2026 | Aucatzyl is an autologous anti-cd19 car-t therapy indicated for adults with relapsed or refractory b-cell... | View |
| P1.002.016 | ENCELTO (Revakinagene taroretcel-lwey) | Sep 22, 2025 | Sep 20, 2026 | Encelto (revakinagene taroretcel-lwey) is a cell-based implant designed to continuously deliver recombinant... | View |
| P1.002.017 | KEBILIDI (Eladocagene exuparvovec-tneq) | Sep 22, 2025 | Sep 20, 2025 | Kebilidi is an adeno-associated virus (aav) vector-based gene therapy 12 indicated for the treatment of adult... | View |
| P1.002.018 | LANTIDRA (Donislecel) | Sep 22, 2025 | Sep 20, 2026 | Lantidra (donislecel-jujn) is an allogeneic pancreatic islet cell therapy approved by the fda in june 2023.... | View |
| P1.002.019 | LAVIV (Azficel-T) | Sep 02, 2025 | Sep 20, 2026 | Azficel-t is an autologous cellular product composed of fibroblasts indicated for improvement of the... | View |
| P1.002.021 | OMISIRGE (Omidubicel-onlv) | Sep 22, 2025 | Sep 20, 2026 | ... | View |
| P1.002.022 | RETHYMIC (Allogeneic processed thymus tissue – agdc) | Sep 22, 2025 | Sep 20, 2026 | Allogeneic processed thymus tissue–agdc (rethymic) was approved by the us food and drug administration... | View |
| P1.002.023 | RYONCIL (Remestemcel-L-rknd) | Sep 22, 2025 | Sep 20, 2026 | Remestemcel-l-rknd (ryoncil) is fda-approved for the treatment of steroid-refractory acute graftversus-host... | View |
| P1.002.024 | SKYSONA (Elivaldogene autotemcel) | Sep 22, 2025 | Sep 20, 2026 | Cerebral adrenoleukodystrophy (cald) is an x-linked genetic neurodegenerative disease that most severely... | View |
| P1.002.026 | TECELRA (Afamitresgene autoleucel) | Sep 22, 2025 | Sep 26, 2026 | Tecelra (afamitresgene autoleucel) is a melanoma-associated antigen a4 (magea4)-directed genetically modified... | View |
| P1.002.028 | AXTLE (pemetrxed) | Sep 22, 2025 | Sep 20, 2026 | Pemetrexed (alimta) was initially approved by the u.s. food and drug administration (fda) in february 2004... | View |
| P1.002.033 | Gefitinib | Sep 22, 2025 | Sep 20, 2026 | Gefitinib (iressa®) is an orally administered tyrosine kinase inhibitor (tki) of the epidermal growth... | 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 11, 2025 | Aug 20, 2026 | 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 |
