Commercial

Medical Policy

Name	MPDispTitle	MPPolicyNumber	Policy Category	Title	MPPolicyPageName	ID	MPTitle	MPPolicyNumberwithoutversion	MPNotificationIssuedDate	MPattachmentdataPub	MPEffectiveDate
dda832ee-a0b1-49f2-80de-061c0f3edee9	Golimumab(SimponiAria®)Intravenous(IV)Injection08.01.15g	08.01.15g	Pharmacy (08)	Golimumab (Simponi Aria®) Intravenous (IV) Injection	dda832ee-a0b1-49f2-80de-061c0f3edee9	5471	Golimumab (Simponi Aria®) Intravenous (IV) Injection	08.01.15	8/1/2023 10:00 AM	{"5472": {"Id":5472,"MPAttachmentLetter":"A","Title":"Medically Necessary ICD-10 Codes","MPPolicyAttachmentInternalSourceId":7466,"PolicyAttachmentPageName":"ef2c976b-9f8e-44ff-8555-fd0fc5eb38df"},}	10/30/2023
15d4fdbe-af50-4e4b-9b1c-6d8ee491d0ab	Tocilizumab(Actemra®)forIntravenousInfusion08.00.85n	08.00.85n	Pharmacy (08)	Tocilizumab (Actemra®) for Intravenous Infusion	15d4fdbe-af50-4e4b-9b1c-6d8ee491d0ab	5483	Tocilizumab (Actemra®) for Intravenous Infusion	08.00.85	8/16/2023 10:00 AM	{"5484": {"Id":5484,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7468,"PolicyAttachmentPageName":"d13aec89-9dd0-4ddd-a6f9-d8a787664e9d"},}	11/13/2023
1a6bddc6-a618-4287-8360-450516d7023b	Daratumumab(Darzalex®),DaratumumabandHyaluronidase-fihj(DarzalexFaspro®)08.01.29k	08.01.29k	Pharmacy (08)	Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)	1a6bddc6-a618-4287-8360-450516d7023b	5514	Daratumumab (Darzalex®), Daratumumab and Hyaluronidase-fihj (Darzalex Faspro®)	08.01.29	8/29/2023 2:00 PM		11/27/2023
b54e7ec4-dc44-418c-8fd0-1e1c2ad712f5	Abatacept(Orencia®)forInjectionforIntravenousUse08.00.62p	08.00.62p	Pharmacy (08)	Abatacept (Orencia®) for Injection for Intravenous Use	b54e7ec4-dc44-418c-8fd0-1e1c2ad712f5	5543	Abatacept (Orencia®) for Injection for Intravenous Use	08.00.62	9/12/2023 11:00 AM	{"5544": {"Id":5544,"MPAttachmentLetter":"A","Title":"ICD-10 CODES AND NARRATIVES","MPPolicyAttachmentInternalSourceId":7512,"PolicyAttachmentPageName":"8208ab03-d005-451f-8bf2-5e1cfee36282"},}	12/11/2023
4f4f2c65-9768-43af-81cf-7b151317458c	NebulizersandInhalationSolutions05.00.15t	05.00.15t	DME (05)	Nebulizers and Inhalation Solutions	4f4f2c65-9768-43af-81cf-7b151317458c	5588	Nebulizers and Inhalation Solutions	05.00.15	9/29/2023 11:00 AM		1/1/2024

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