Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   

Policy #
Policy Bulletin Title
Show details for
MA08.028c
Abatacept (Orencia®) for Injection for Intravenous Use
Show details for
MA08.066c
Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.033b
Agalsidase beta (Fabrazyme®)
MA08.015c
Alemtuzumab (Lemtrada™)
MA08.036c
Alglucosidase alfa (e.g., Lumizyme®)
MA08.050a
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
Show details for
MA08.091c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
MA08.085b
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
MA08.057a
Belimumab (Benlysta®) for Intravenous Use
Show details for
MA08.072e
Bevacizumab (Avastin®) and Related Biosimilars
MA08.058c
Blinatumomab (Blincyto®)
MA08.037f
Bortezomib (Bortezomib for Injection, Velcade®)
Show details for
MA08.017d
Botulinum Toxin Agents
Show details for
MA08.068d
Brentuximab Vedotin (Adcetris®)
MA08.099a
Burosumab-twza (Crysvita®)
MA08.054b
Cabazitaxel (Jevtana®)
MA08.101
Canakinumab (Ilaris®)
MA08.062d
Carfilzomib (Kyprolis™)
MA08.089c
Cerliponase alfa (Brineura®)
Show details for
MA08.031d
Cetuximab (Erbitux®)
MA08.093e
Chimeric Antigen Receptor (CAR) Therapy
MA08.004p
Coagulation Factors
MA08.079e
Daratumumab (Darzalex™)
Show details for
MA08.052g
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
MA08.074
Deoxycholic Acid (Kybella™)
MA08.021b
Dofetilide (Tikosyn®) Use in the Inpatient Setting
MA08.044e
Eculizumab (Soliris®) and Related Biosimilars, Ravulizumab-cwvz (Ultomiris™)
MA08.092a
Edaravone (Radicava™)
MA08.104b
Emapalumab-lzsg (Gamifant®)
MA08.003d
Enteral Nutritional Therapy
MA08.023b
Enzyme Replacement for the Treatment of Gaucher's Disease
MA08.034d
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
Show details for
MA08.056c
Eribulin Mesylate (Halaven®)
MA08.011e
Erythropoiesis Stimulating Agents (ESAs)
MA08.114
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
Show details for
MA08.070c
Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.083b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
MA08.096a
Ibalizumab-uiyk (Trogarzo™)
Show details for
MA08.009h
Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
Show details for
MA08.019f
Infliximab and Related Biosimilars
MA08.024f
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra®)
Show details for
MA08.073f
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
Show details for
MA08.059f
Ipilimumab (Yervoy®)
Show details for
MA08.090b
Lanreotide (Somatuline® Depot)
MA08.110
Luspatercept–aamt (Reblozyl®)
Show details for
MA08.007q
Medicare Part B vs. Part D Crossover Drugs
MA08.102b
Mogamulizumab-kpkc (Poteligeo®)
MA08.103b
Moxetumomab pasudotox-tdfk (Lumoxiti™)
MA08.029b
Natalizumab (Tysabri®)
MA08.086d
Nusinersen (Spinraza®)
MA08.088c
Ocrelizumab (Ocrevus®)
Show details for
MA08.065e
Octreotide Acetate (Sandostatin® LAR Depot)
MA08.048d
Ofatumumab (Arzerra™)
MA08.012b
Off-label Coverage for Prescription Drugs and/or Biologics
Show details for
MA08.025c
Omalizumab (Xolair®)
Show details for
MA08.049f
Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
MA08.100b
Patisiran (Onpattro™)
Hide details for
MA08.082a
Pegfilgrastim (Neulasta®) and Related Biosimilars
MA08.082a
Attachment A (EXAMPLES OF DISEASE SETTINGS AND CHEMOTHERAPY REGIMENS WITH A HIGH (>20%) OR INTERMEDIATE (10-20%) RISK FOR FEBRILE NEUTROPENIA) to MA08.082a Pegfilgrastim (Neulasta®) and Related Biosimilars
Show details for
MA08.060d
Pegloticase (Krystexxa®)
Show details for
MA08.047d
Pemetrexed (Alimta®)
MA08.053a
Personalized Vaccines (e.g., Provenge®)
Show details for
MA08.063c
Pertuzumab (Perjeta®)
MA08.108b
Polatuzumab Vedotin-Piiq (Polivy™)
Show details for
MA08.043d
Pralatrexate (Folotyn®) for Injection
Show details for
MA08.010j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
MA08.075d
Ramucirumab (Cyramza®)
MA08.067a
Repository Corticotropin (H.P. Acthar® Gel Injection)
Show details for
MA08.022h
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
MA08.078c
Sebelipase alfa (Kanuma®)
MA08.006f
Siltuximab (Sylvant®)
MA08.105b
Tagraxofusp-erzs (Elzonris™)
MA08.098a
Tildrakizumab-asmn (Ilumya™)
Show details for
MA08.045e
Tocilizumab (Actemra®) for Intravenous Infusion
MA08.008d
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN)
Show details for
MA08.018d
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
Show details for
MA08.016e
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
MA08.026f
Treatments for Complex Regional Pain Syndrome (CRPS)
MA08.097a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
MA08.042h
Ustekinumab (Stelara®)
Show details for
MA08.001c
Vedolizumab (Entyvio®)
MA08.094c
Voretigene Neparvovec-rzyl (Luxturna™)









Connect with Us        


© 2017 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.