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
P1.002.027 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
PP.001.001 Dose Rounding of Drug Covered Under The Medical Benefit May 2026 ... View
PP.001.002 Leuprolide May 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 2026 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 2025 The term "discontinued procedure" designates a surgical or diagnostic procedure provided by a... View
PP.002.004 Split Surgical Package Jun 2026 ... View
PP.002.007 Increased Procedural Services (Modifier 22) May 2026 Description: the term “increased procedural services” designates a service provided by a... View
PP.002.008 Discontinued Procedure May 2026 Description: the term discontinued procedure designates a surgical or diagnostic procedure provided by a... View
PP.002.009 Reduced Services May 2026 As defined in the current procedural terminology (cpt®) book, a reduced service is where a service or... View
PP.002.010 Sleep Studies Jun 2026 This payment policy describes reimbursement guidelines applicable to sleep studies including polysomnography.... View
V5.003.004 Gene Therapies for Duchenne Muscular Dystrophy Jun 2026 Duchenne muscular dystrophy (dmd) is an inherited disorder that results in progressive muscle weakness and... View