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
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MA08.028c
Abatacept (Orencia®) for Injection for Intravenous Use
MA08.028c
Attachment A (ICD-10 codes) to MA08.028c Abatacept (Orencia®) for Injection for Intravenous Use
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MA08.066c
Ado-Trastuzumab Emtansine (Kadcyla®)
MA08.066c
Attachment A (ICD-10 CODES AND NARRATIVES) to 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™)
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MA08.091c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
MA08.091c
Attachment A (Risk of Emesis Without Prophylaxis: Intravenous and Oral Antineoplastic Agents) to 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
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MA08.072e
Bevacizumab (Avastin®) and Related Biosimilars
MA08.072e
Attachment A (Dosing and Frequency Requirements) to MA08.072e Bevacizumab (Avastin®) and Related Biosimilars
MA08.058c
Blinatumomab (Blincyto®)
MA08.037f
Bortezomib (Bortezomib for Injection, Velcade®)
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MA08.017d
Botulinum Toxin Agents
MA08.017d
Attachment A (ICD-10 Diagnosis Codes) to MA08.017d Botulinum Toxin Agents
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MA08.068d
Brentuximab Vedotin (Adcetris®)
MA08.068d
Attachment A (ICD 10 CODES AND NARRATIVES) to 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®)
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MA08.031d
Cetuximab (Erbitux®)
MA08.031d
Attachment A (Dosing and Frequency Requirements) to MA08.031d Cetuximab (Erbitux®)
MA08.031d
Attachment B (ICD-10 Codes for Cetuximab (Erbitux®)) to MA08.031d Cetuximab (Erbitux®)
MA08.093e
Chimeric Antigen Receptor (CAR) Therapy
MA08.004p
Coagulation Factors
MA08.079e
Daratumumab (Darzalex™)
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MA08.052g
Denosumab (Prolia®, Xgeva®), Romosozumab-aqqg (Evenity™)
MA08.052g
Attachment A (ICD-10-CM Codes) to 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.)
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MA08.056c
Eribulin Mesylate (Halaven®)
MA08.056c
Attachment A (ICD-10 Codes and Narratives ) to MA08.056c Eribulin Mesylate (Halaven®)
MA08.011e
Erythropoiesis Stimulating Agents (ESAs)
MA08.114
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
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MA08.070c
Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.070c
Attachment A (Medically Necessary ICD-10 Codes) to MA08.070c Golimumab (Simponi® Aria™) Intravenous (IV) Injection
MA08.083b
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
MA08.096a
Ibalizumab-uiyk (Trogarzo™)
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MA08.009h
Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA08.009h
Attachment A (ICD-10 DIAGNOSIS CODES) to MA08.009h Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
MA08.009h
Attachment B (Dosage and Frequency Requirements) to MA08.009h Immune Globulin: Intravenous (IVIG), Subcutaneous (SCIG)
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MA08.019f
Infliximab and Related Biosimilars
MA08.019f
Attachment A (Dosing and Frequency Requirements for Infliximab and Related Biosimilars) to MA08.019f Infliximab and Related Biosimilars
MA08.019f
Attachment B (ICD-10-CM codes) to 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®)
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MA08.073f
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
MA08.073f
Attachment A (ICD-10 Codes and Narratives) to MA08.073f Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists and Related Biosimilars
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MA08.059f
Ipilimumab (Yervoy®)
MA08.059f
Attachment A (Dosing and Frequency Requirements For Ipilimumab (Yervoy®)) to MA08.059f Ipilimumab (Yervoy®)
MA08.059f
Attachment B (ICD-10 Diagnosis codes) to MA08.059f Ipilimumab (Yervoy®)
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MA08.090b
Lanreotide (Somatuline® Depot)
MA08.090b
Attachment A to MA08.090b Lanreotide (Somatuline® Depot)
MA08.110
Luspatercept–aamt (Reblozyl®)
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MA08.007q
Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment A (Part B drugs that can be accessed through the Part D pharmacy benefit: pharmacy claims process at Medicare Part B cost share with no true out-of-pocket (TrOOP) expenses applied) to MA08.007q Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment B (Drugs that are usually self-administered: considered Part D only – excluded from Part B coverage) to MA08.007q Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment C (Vaccination and inoculation coverage.) to MA08.007q Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment D (Hepatitis B vaccine indications and diagnosis codes that are covered under the Medicare medical benefit (Part B).) to MA08.007q Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment E (Indications for when selected drugs that are being administered on an external infusion pump are covered under the Medicare medical benefit Part B) to MA08.007q Medicare Part B vs. Part D Crossover Drugs
MA08.007q
Attachment F (Diagnosis codes that represent primary immunodeficiencies that are covered under the Medicare medical benefit (Part B) for intravenous immune globulin when given in the home setting) to 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®)
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MA08.065e
Octreotide Acetate (Sandostatin® LAR Depot)
MA08.065e
Attachment A (ICD 10 codes and narratives) to MA08.065e Octreotide Acetate (Sandostatin® LAR Depot)
MA08.048d
Ofatumumab (Arzerra™)
MA08.012b
Off-label Coverage for Prescription Drugs and/or Biologics
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MA08.025c
Omalizumab (Xolair®)
MA08.025c
Attachment A (Dosing and Frequency Requirements for Omalizumab (Xolair®)) to MA08.025c Omalizumab (Xolair®)
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MA08.049f
Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
MA08.049f
Attachment A (ICD-10 codes) to MA08.049f Paclitaxel Protein-Bound Particles for Injectable Suspension (Albumin-bound)/(Abraxane® for Injectable Suspension)
MA08.100b
Patisiran (Onpattro™)
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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
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MA08.060d
Pegloticase (Krystexxa®)
MA08.060d
Attachment A (ICD-10 Codes and Narratives) to MA08.060d Pegloticase (Krystexxa®)
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MA08.047d
Pemetrexed (Alimta®)
MA08.047d
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.047d Pemetrexed (Alimta®)
MA08.053a
Personalized Vaccines (e.g., Provenge®)
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MA08.063c
Pertuzumab (Perjeta®)
MA08.063c
Attachment A (ICD-10-CM Codes and Narratives) to MA08.063c Pertuzumab (Perjeta®)
MA08.108b
Polatuzumab Vedotin-Piiq (Polivy™)
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MA08.043d
Pralatrexate (Folotyn®) for Injection
MA08.043d
Attachment A (ICD-10 Codes Eligible to be Reported for Pralatrexate (Folotyn®) for Injection) to MA08.043d Pralatrexate (Folotyn®) for Injection
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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™)
MA08.010j
Attachment A (ICD-10 Codes and Narratives) to 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)
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MA08.022h
Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
MA08.022h
Attachment A (Dosing and Frequency Requirements For Rituximab (Rituxan®) infusion and related biosimilars, and rituximab/hyaluronidase human for subcutaneous injection (Rituxan Hycela®)) to MA08.022h Rituximab (Rituxan®) Infusion and Related Biosimilars, and Rituximab/Hyaluronidase Human for Subcutaneous Injection (Rituxan Hycela®)
MA08.022h
Attachment B (ICD-10 CODES AND NARRATIVES) to 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™)
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MA08.045e
Tocilizumab (Actemra®) for Intravenous Infusion
MA08.045e
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.045e Tocilizumab (Actemra®) for Intravenous Infusion
MA08.008d
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Nutrition (IPN)
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MA08.018d
Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
MA08.018d
Attachment A (Dosing & Frequency Requirements for Trastuzumab (Herceptin®)) to MA08.018d Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
MA08.018d
Attachment B (ICD-10 CM Codes and Narratives) to MA08.018d Trastuzumab (Herceptin®) and Related Biosimilars, Trastuzumab and Hyaluronidase-oysk (Herceptin Hylecta)
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MA08.016e
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
MA08.016e
Attachment A ( Dosing and Frequency Requirements) to 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®)
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MA08.001c
Vedolizumab (Entyvio®)
MA08.001c
Attachment A (ICD-10 CODES AND NARRATIVES) to MA08.001c Vedolizumab (Entyvio®)
MA08.094c
Voretigene Neparvovec-rzyl (Luxturna™)









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