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 |
|---|---|---|---|---|---|
| M5.001.022 | Ultomiris® (ravulizumab-cwvz) | May 14, 2025 | May 20, 2025 | Ravulizumab-cwvz is a complement inhibitor indicated as a treatment for adult patients, 18 years and older,... | View |
| M5.001.023 | Soliris (eculizumab) | Aug 22, 2024 | Aug 20, 2025 | Soliris is a complement inhibitor indicated for the treatment of patients with paroxysmal nocturnal... | View |
| M5.001.024 | Adstiladrin® (nadofaragene firadenovec-vncg) | Feb 20, 2025 | Oct 20, 2025 | Adstiladrin is a non-replicating adenoviral vector-based gene therapy indicated for the treatment of adult... | View |
