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Políticas Médicas
Las políticas médicas son documentos que definen el reconocimiento de cubierta para tecnologías, procedimientos y tratamientos. Las declaraciones de necesidad médica en las políticas, sobre si una tecnología, procedimiento, tratamiento, suplido, equipo, medicamento u otro servicio mejora el resultado en la salud de la población para la cual dicha tecnología o tratamiento fue diseñado se basan en evidencia científica, estudios clínicos y opiniones profesionales de nuestros proveedores y de las organizaciones médicas reconocidas.
Cada documento desplegado en este sitio Web se provee con propósitos informativos solamente y no es una autorización, explicación de beneficios o un contrato. El recibir beneficios está sujeto a la satisfacción de todos los términos y condiciones de la cubierta. La tecnología médica cambia constantemente y nos reservamos el derecho de revisar y actualizar nuestras políticas periódicamente.
| ID | Título | Última Revisión | Siguiente Revisión | Descripción | Acceso |
|---|---|---|---|---|---|
| P01.001.002 | Beovu | Jul 08, 2022 | Jul 08, 2023 | Beovu is covered under the medical benefit when used within the following guidelines. use outside of these... | Ver |
| P1.001.001 | ADAKVEO® (crizanlizumab-tmca) | Sep 17, 2024 | Sep 20, 2025 | Adakveo may be considered medically necessary in patients 16 years of age or older with vasoocclusive crises... | Ver |
| P1.001.004 | DANYELZA® (naxitamab-gqgk) | Sep 17, 2024 | Sep 20, 2025 | Initiation of danyelza meets the definition of medical necessity when used to treat the following indication... | Ver |
| P1.001.005 | JEMPERLI (dostarlimab-gxly) | Sep 17, 2024 | Sep 20, 2025 | Policy statements jemperli may be considered medically necessary if the conditions below are... | Ver |
| P1.001.006 | MARGENZA® (margetuximab-cmkb) | Sep 17, 2024 | Sep 20, 2025 | Margenza may be considered medically necessary in patients 18 years of age or older for the treatment of... | Ver |
| P1.001.007 | MONJUVI® (tafasitamab-cxix) | Sep 17, 2024 | Sep 20, 2025 | Monjuvi may be considered medically necessary in patients 18 years of age or older for the treatment of adult... | Ver |
| P1.001.008 | RYBREVANT® (amivantamab-vmjw) | Sep 17, 2024 | Sep 20, 2025 | Rybrevant may be considered medically necessary in patients 18 years of age or older for the treatment of... | Ver |
| P1.001.009 | ELAHERE® (mirvetuximab soravtansine-gynx) | Sep 17, 2024 | Sep 20, 2025 | Initiation of elahere meets the definition of medical necessity when used to treat the following indication... | Ver |
| P1.001.010 | BRIUMVI® (ublituximab-xiiy) | Oct 09, 2024 | Sep 20, 2025 | Initiation of ublituximab-xiiy (briumvi) meets the definition of medical necessity when all the criteria... | Ver |
| P1.001.011 | IMJUDO® (tremelimumab-actl) | Sep 17, 2024 | Sep 20, 2025 | Initiation of imjudo meets the definition of medical necessity when used to treat the established indications... | Ver |
| P1.001.012 | TECVAYLI® (teclistamab-cqyv) | Sep 17, 2024 | Sep 20, 2025 | Initiation of teclistamab (tecvayli) meets the definition of medical necessity when all the criteria below... | Ver |
| P1.001.013 | ENJAYMO® (sutimlimab-jome) | Sep 17, 2024 | Sep 20, 2025 | Enjaymo may be considered medically necessary in adult patients for the of hemolysis in adults with cold... | Ver |
| P1.001.014 | OPDUALAG™ (nivolumab and relatlimab-rmbw) | Sep 17, 2024 | Sep 20, 2025 | Opdualag may be considered medically necessary in patients 12 years of age or older at least 40 kg for the... | Ver |
| P1.001.015 | XENPOZYME® (olipudase alfa-rpcp) | Sep 17, 2024 | Sep 20, 2025 | Xenopozyme may be considered medically necessary in adult and pediatric patients for the treatment of... | Ver |
| P1.001.016 | FYARRO™ (sirolimus protein-bound particles for injectable suspension) | Sep 17, 2024 | Sep 20, 2025 | Coverage eligibility for sirolimus protein-bound particles (fyarro) will be considered when the following... | Ver |
| P1.002.001 | Entyvio® (vedolizumab) | Dec 16, 2024 | Dec 20, 2024 | Coverage is provided in the following conditions: • patient is at least 18 years of age; and •... | Ver |
| P1.002.002 | Fasenra® (benralizumab) | Dec 17, 2024 | Dec 20, 2025 | Coverage is provided in the following conditions: universal criteria must not be used in... | Ver |
| P1.002.003 | Somatuline® Depot; Lanreotide | Dec 17, 2024 | Dec 20, 2025 | Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... | Ver |
| P1.002.004 | Nucala® (mepolizumab) | Dec 17, 2024 | Dec 20, 2025 | Coverage is provided in the following conditions: universal criteria ï· must not be used in... | Ver |
| P1.002.005 | Ocrevus™ (ocrelizumab) | Dec 17, 2024 | Dec 20, 2025 | Initiation of ocrelizumab (ocrevus) meets the definition of medical necessity when all the criteria below is... | Ver |
