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 |
|---|---|---|---|---|---|
| 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.001.004 | Coverage Guideline for Orphan Drugs and Off-Label and Labeled Use of FDA Approved Drugs | Jan 13, 2026 | Jan 20, 2027 | Triple s salud has a procedure designed to ensure the evaluation of requests for coverage of covered... | 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 23, 2025 | Jun 20, 2026 | ... | View |
