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 |
|---|---|---|---|---|
| P01.001.001 | Adakveo | Jul 2022 | Adakveo is a prescription medicine used to treat the symptoms of sickle cell disease. adakveo may be used... | View |
| P01.001.002 | Beovu | Jul 2022 | Beovu is a prescription medicine used to treat neovascular (wet) age-related macular degeneration (amd) and... | View |
| P1.001.001 | Adakveo | Sep 2025 | Adakveo® is an iv p-selectin inhibitor approved by the fda for reducing vaso-occlusive crises (voc) in... | View |
| P1.001.004 | Danyelza | Sep 2025 | Danyelza (naxitamab-gqgk) is a gd2-binding monoclonal antibody indicated, in combination with... | View |
| P1.001.005 | Jemperli | Sep 2025 | Jemperli is a programmed death receptor-1 (pd-1)–blocking antibody indicated for: endometrial cancer... | View |
| P1.001.006 | Margenza | Sep 2025 | Margenza (margetuximab-cmkb) is a her2/neu receptor antagonist indicated, in combination with chemotherapy,... | View |
| P1.001.007 | Monjuvi | Sep 2025 | Monjuvi (tafasitamab-cxix) is a cd19-directed cytolytic antibody indicated, in combination with lenalidomide,... | View |
| P1.001.008 | Rybrevant | Sep 2025 | Rybrevant (amivantamab-vmjw) is a bispecific egf receptor-directed and met receptor-directed antibody... | View |
| P1.001.009 | Elahere (mirvetuximab soravtansine-gynx) | Sep 2025 | Elahere (mirvetuximab soravtansine-gynx) is a folate receptor alpha (frα)-directed antibody–drug... | View |
| P1.001.010 | Ublituximab-xiiy (Briumvi) | Apr 2026 | Briumvi (ublituximab-xiiy) is a cd20-directed monoclonal antibody indicated for the treatment of adults with... | View |
| P1.001.011 | Imjudo (tremelimumab-actl) injection | Sep 2025 | Imjudo (tremelimumab-actl) is a cytotoxic t-lymphocyte–associated antigen 4 (ctla-4) blocking antibody... | View |
| P1.001.012 | Teclistamab (Tecvayli) | Sep 2025 | Teclistamab (tecvayli) is a bispecific b-cell maturation antigen (bcma)-directed cd3 t-cell engaging antibody... | View |
| P1.001.013 | Enjaymo | Sep 2025 | Sutimlimab-jome (enjaymo) is a monoclonal antibody that inhibits the classical complement pathway by binding... | View |
| P1.001.014 | Opdualag | Sep 2025 | Opdualag (nivolumab + relatlimab-rmbw) is a fixed-dose combination of two immune checkpoint inhibitors:... | View |
| P1.001.015 | Xenpozyme | Sep 2025 | Xenpozyme® (olipudase alfa-rpcp) is an enzyme replacement therapy (ert) for the treatment of non-cns... | View |
| P1.001.016 | Fyarro | Sep 2025 | Fyarro™ (nab-sirolimus) is an mtor inhibitor formulated as sirolimus protein-bound particles... | View |
| P1.002.001 | Vedolizumab | Dec 2025 | Vedolizumab is a recombinant human igg1 monoclonal antibody produced in chinese hamster ovaries. it binds to... | View |
| P1.002.002 | Benralizumab | Apr 2026 | Benralizumab is an interleukin-5 antagonist monoclonal antibody (igg1 kappa) for the add-on maintenance... | View |
| P1.002.003 | Somatuline® Depot; Lanreotide | Apr 2026 | Somatuline® depot; lanreotide is used to treat people with acromegaly (condition in which the body... | View |
| P1.002.004 | Nucala® (mepolizumab) | Dec 2025 | Nucala (mepolizumab) is an interleukin-5 receptor antagonist indicated for add-on maintenance treatment of... | View |