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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08.00.62i
Abatacept (Orencia®) for Injection for Intravenous Use
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08.01.11d
Ado-Trastuzumab Emtansine (Kadcyla®)
08.00.69b
Agalsidase beta (Fabrazyme®)
08.01.22c
Alemtuzumab (Lemtrada®)
08.00.72h
Alglucosidase alfa (e.g., Lumizyme®)
08.00.91c
Alpha 1-Antitrypsin Therapy (e.g., Prolastin-C®, Aralast NP™, Glassia™, Zemaira™)
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08.01.41c
Aprepitant (Cinvanti™), Fosaprepitant Dimeglumine (Emend®), Granisetron (Sustol®), and Rolapitant (Varubi®)
08.01.35a
Asparaginase Erwinia Chrysanthemi (Erwinaze®)
08.01.03c
Belatacept (Nulojix®)
08.00.99b
Belimumab (Benlysta®) for Intravenous Use
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08.00.66k
Bevacizumab (Avastin®) and related biosimilars
08.01.21c
Blinatumomab (Blincyto®)
08.00.73l
Bortezomib (Bortezomib for Injection, Velcade®)
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08.00.26u
Botulinum Toxin Agents
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08.01.13c
Brentuximab Vedotin (Adcetris®)
08.01.49a
Burosumab-twza (Crysvita®)
08.00.96d
Cabazitaxel (Jevtana®)
08.01.51
Canakinumab (Ilaris®)
08.01.05e
Carfilzomib (Kyprolis™)
08.01.39c
Cerliponase alfa (Brineura®)
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08.00.67k
Cetuximab (Erbitux®)
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08.01.43d
Chimeric Antigen Receptor (CAR) Therapy
08.00.92y
Coagulation Factors
08.01.08d
Coverage of Prescription Oral Anticancer Drugs and/or Biologics as Provided Under the Company's Medical Benefit
08.01.29d
Daratumumab (Darzalex™)
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08.00.94k
Denosumab (Prolia®, Xgeva®)
08.01.24
Deoxycholic Acid (Kybella™)
08.00.49d
Dofetilide (Tikosyn®) Use in the Inpatient Setting
08.01.37
Drugs Used for the Maintenance Treatment of Opioid or Alcohol Use Disorder (e.g., Probuphine Implant, Vivitrol Injection)
08.00.84d
Eculizumab (Soliris®)
08.01.42a
Edaravone (Radicava™)
08.01.54
Emapalumab-lzsg (Gamifant®)
08.00.51j
Enzyme Replacement for the Treatment of Gaucher's Disease
08.01.26a
Enzyme Replacement Therapy for Adenosine Deaminase Severe Combined Immune Deficiency (e.g., pegademase bovine [Adagen®], elapegademase-lvlr [Revcovi™])
08.00.70e
Enzyme Replacement Therapy for Mucopolysaccharidosis (e.g., Aldurazyme®, Elaprase®, Vimizim®, Naglazyme®, Mepsevii™, etc.)
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08.00.98e
Eribulin Mesylate (Halaven®)
08.00.75m
Erythropoiesis-Stimulating Agents (ESAs)
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08.01.15d
Golimumab (Simponi Aria®) Intravenous (IV) Injection
08.01.33a
Gonadotropin-Releasing Hormone Agonist (Eligard®, Lupron Depot®)
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08.00.97h
Histone Deacetylase Inhibitors for Peripheral T-cell Lymphoma (e.g., Istodax®, Beleodaq®)
08.01.00g
Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies
08.01.46a
Ibalizumab-uiyk (Trogarzo™)
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08.00.13t
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.22m
Immune Prophylaxis for Respiratory Syncytial Virus (RSV)
08.01.04t
Immunizations
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08.00.34m
Infliximab and Related Biosimilars
08.01.23e
Interleukin-5 (IL-5) Antagonist (e.g., Cinqair®, Nucala®) and IL-5 Receptor Antagonist (e.g., Fasenra™)
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08.00.74l
Intravitreal Injection of Vascular Endothelial Growth Factor (VEGF) Antagonists (e.g., ranibizumab [Lucentis®], pegaptanib sodium [Macugen®], aflibercept [Eylea®], and related biosimilars)
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08.01.01h
Ipilimumab (Yervoy®)
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08.01.40a
Lanreotide (Somatuline® Depot)
08.01.52
Mogamulizumab-kpkc (Poteligeo®)
08.01.53a
Moxetumomab Pasudotox-tdfk (Lumoxiti™)
08.00.64f
Natalizumab (Tysabri®)
08.01.36d
Nusinersen (Spinraza®)
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08.00.18m
Nutritional Formulas, Enteral Nutrition, Medical Foods, Low-Protein Modified Food Products, and Donated Breast Milk
08.01.38b
Ocrelizumab (Ocrevus™)
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08.01.10d
Octreotide acetate (Sandostatin® LAR Depot)
08.00.88e
Ofatumumab (Arzerra™)
08.00.15e
Off-label Coverage for Prescription Drugs and/or Biologics
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08.00.55h
Omalizumab (Xolair®)
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08.00.90i
Paclitaxel Protein-bound Particles for Injectable Suspension (Albumin-bound) / (Abraxane® for Injectable Suspension)
08.01.50a
Patisiran (Onpattro™)
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08.01.32a
Pegfilgrastim (Neulasta®) and Related Biosimilars
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08.01.02d
Pegloticase (Krystexxa®)
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08.00.87e
Pemetrexed (Alimta®)
08.00.95d
Personalized Vaccines (e.g. Provenge®)
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08.01.07e
Pertuzumab (Perjeta®)
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08.00.83g
Pralatrexate (Folotyn®) for Injection
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08.01.20j
Programmed Death Receptor-1 (PD-1) Antagonists (e.g., Keytruda®, Opdivo®) and Programmed Death-Ligand 1 (PD-L1) Antagonists (e.g., Tecentriq®, Bavencio®, Imfinzi™)
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (Independence Administrators)
08.01.14e
Radium Ra 223 dichloride (Xofigo®) Injection (Independence Administrators)
08.01.25c
Ramucirumab (Cyramza®)
08.01.12b
Repository Corticotropin (H.P. Acthar® Gel Injection)
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08.00.50r
Rituximab (Rituxan®) infusion, and rituximab and hyaluronidase human (Rituxan Hycela™) for subcutaneous injection
08.01.28c
Sebelipase alfa (Kanuma®)
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08.00.78aa
Self-Administered Drugs
08.01.19e
Siltuximab (Sylvant®)
08.01.55
Tagraxofusp-erzs (Elzonris™)
08.01.27d
Talimogene laherparepvec (Imlygic™)
08.01.48a
Tildrakizumab-asmn (Ilumya™)
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08.00.85h
Tocilizumab (Actemra®) for Intravenous Infusion
08.00.17g
Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)
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08.00.33l
Trastuzumab (Herceptin®) and Related Biosimilars
08.00.25k
Treatment of Pulmonary Artery Hypertension with Intravenous, Subcutaneous, and Inhaled Pharmacologic Agents
08.00.57m
Treatments for Complex Regional Pain Syndrome (CRPS)
08.01.47a
Triamcinolone Acetonide Extended-Release Injectable (Zilretta™)
08.00.82j
Ustekinumab (Stelara®)
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08.01.18c
Vedolizumab (Entyvio®)
08.01.44c
Voretigene Neparvovec-rzyl (Luxturna™)

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