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 |
|---|---|---|---|---|
| P1.002.008 | Tysabri® (natalizumab) | Dec 2025 | Natalizumab (tysabri) is a humanized monoclonal antibody that binds to alpha-4 integrin expressed on the... | View |
| P1.002.009 | Xolair® (omalizumab) | Dec 2025 | Omalizumab is an anti-ige monoclonal antibody produced by recombinant dna technology using chinese hamster... | View |
| P1.002.010 | Ruconest (C1 Esterase Inhibitor [recombinant]) | Sep 2025 | Ruconest is a recombinant c1 esterase inhibitor indicated for the treatment of acute attacks of hereditary... | View |
| P1.002.011 | Ultomiris® (ravulizumab-cwvz) | Jun 2025 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| P1.002.012 | Soliris (eculizumab) | Jan 2026 | Soliris is a complement inhibitor indicated for the treatment of patients with paroxysmal nocturnal... | View |
| P1.002.013 | Adstiladrin® (nadofaragene firadenovec-vncg) | Feb 2026 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
| P1.002.014 | AMTAGVI (Lifileucel) | Sep 2025 | Amtagvi (lifileucel) is an autologous til (tumor-infiltrating lymphocyte) therapy approved by the fda in... | View |
| P1.002.015 | AUCATZYL (Obecabtagene autoleucel) | May 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) | May 2026 | Encelto (revakinagene taroretcel-lwey) is a cell-based implant designed to continuously deliver recombinant... | View |
| P1.002.017 | KEBILIDI (Eladocagene exuparvovec-tneq) | Sep 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 2025 | 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 2025 | Azficel-t is an autologous cellular product composed of fibroblasts indicated for improvement of the... | View |
| P1.002.021 | OMISIRGE (Omidubicel-onlv) | Sep 2025 | ... | View |
| P1.002.022 | RETHYMIC (Allogeneic processed thymus tissue – agdc) | Sep 2025 | Allogeneic processed thymus tissue–agdc (rethymic) was approved by the us food and drug administration... | View |
| P1.002.023 | RYONCIL (Remestemcel-L-rknd) | Sep 2025 | Remestemcel-l-rknd (ryoncil) is fda-approved for the treatment of steroid-refractory acute graftversus-host... | View |
| P1.002.024 | SKYSONA (Elivaldogene autotemcel) | Sep 2025 | Cerebral adrenoleukodystrophy (cald) is an x-linked genetic neurodegenerative disease that most severely... | View |
| P1.002.026 | TECELRA (Afamitresgene autoleucel) | Sep 2025 | Tecelra (afamitresgene autoleucel) is a melanoma-associated antigen a4 (magea4)-directed genetically modified... | View |
| P1.002.027 | ZEVASKYN (Prademagene zamikeracel) | Mar 2026 | Zevaskyn is composed of autologous cells isolated from skin punch biopsies of patients with mutations in the... | View |
| P1.002.028 | AXTLE (pemetrxed) | Sep 2025 | Pemetrexed (alimta) was initially approved by the u.s. food and drug administration (fda) in february 2004... | View |
| P1.002.033 | Gefitinib | Sep 2025 | Gefitinib (iressa®) is an orally administered tyrosine kinase inhibitor (tki) of the epidermal growth... | View |