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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
P1.001.010 Ublituximab-xiiy (Briumvi) Sep 20, 2023 Sep 20, 2024 Initiation of ublituximab-xiiy (briumvi) meets the definition of medical necessity when all the criteria... Ver
P1.001.011 Imjudo (tremelimumab-actl) Sep 20, 2023 Sep 20, 2024 Initiation of imjudo meets the definition of medical necessity when used to treat the established indications... Ver
P1.001.012 Teclistamab (Tecvayli) Sep 20, 2023 Sep 20, 2024 Initiation of teclistamab (tecvayli) meets the definition of medical necessity when all the criteria below... Ver
P1.001.013 Enjaymo Sep 20, 2023 Sep 20, 2024 Enjaymo may be considered medically necessary in adult patients for the of hemolysis in adults with cold... Ver
P1.001.014 Opdualag Sep 20, 2023 Sep 20, 2024 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 Sep 20, 2023 Sep 20, 2024 Xenopozyme may be considered medically necessary in adult and pediatric patients for the treatment of... Ver
P1.001.016 Fyarro Sep 20, 2023 Sep 20, 2024 Coverage eligibility for sirolimus protein-bound particles (fyarro) will be considered when the following... Ver
P1.002.001 Entyvio® (vedolizumab) Dec 04, 2023 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 04, 2023 Dec 20, 2024 Coverage is provided in the following conditions: universal criteria  must not be used in... Ver
P1.002.003 Somatuline® Depot; Lanreotide Dec 04, 2023 Dec 20, 2024 Somatuline® depot; lanreotide may be considered medically necessary in patients 18 years of age or older... Ver
P1.002.004 Nucala® (mepolizumab) Dec 04, 2023 Dec 20, 2024 Coverage is provided in the following conditions: universal criteria  must not be used in... Ver
P1.002.005 Ocrevus™ (ocrelizumab) Dec 04, 2023 Dec 20, 2024 Coverage is provided in the following conditions:  patient is 18 years or older (unless otherwise... Ver
P1.002.006 Simponi ARIA® (golimumab) Dec 04, 2023 Dec 20, 2024 Coverage is provided in the following conditions: patient is at least 18 years of age, unless otherwise... Ver
P1.002.007 Stelara® (ustekinumab) Dec 04, 2023 Dec 20, 2024 Stelara® (ustekinumab) may be considered medically necessary if the following conditions are met: patient... Ver
P1.002.008 Tysabri (natalizumab) Dec 04, 0202 Dec 20, 2024 Initial approval criteria • patient is at least 18 years of age; and universal criteria 1,13 •... Ver
P1.002.009 Xolair® (omalizumab) Dec 04, 2023 Dec 20, 2024 Coverage is provided in the following conditions: • patient is at least 18 years of age (unless otherwise... Ver
P1.002.010 Ruconest (C1 Esterase Inhibitor [recombinant]) Feb 19, 2024 Feb 20, 2025 Coverage is provided in the following conditions: • patient is at least 13 years of age; and... Ver
PP.001.001 Dose Rounding of Drug Covered Under The Medical Benefit May 11, 2023 May 20, 2024 I. dose rounding for infused drug products to the nearest lowest vial size if within... Ver
PP.001.002 Leuprolide Aug 29, 2023 Jul 20, 2024 Initial approval criteria a. prostate cancer (must meet all): 1. diagnosis of prostate cancer; 2.... Ver
PP.002.001 Readmissions Review Quality Program (RRQP) Mar 01, 2024 Mar 01, 2025 Triple-s shall evaluate readmissions, either at the claims level or during the readmission. payment for... Ver
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