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Medical Policies

Page of 12, showing Documents 1-10 of 111

Documents for Medical Policies

  • /app/files/public/8484/DHP9457-abatacept-ORENCIA.pdf Abatacept (ORENCIA) Show Details
    Description
    ORENCIA requires prior authorization through Navitus and is considered medically appropriate when one of the following are met: Adult patients with active rheumatoid arthritis who have had an inadequate response TNF antagonist therapies. OR Patient must have a trial of therapy with infliximab (REMICADE) or golimumab (SIMPONI ARIA). ORENCIA is restricted to Rheumatology Specialists.
    Last Updated
    11/4/2015
  • /app/files/public/4641/pdf-medicalpolicies-9202Abor.pdf Abortions (Surgical or Pharmacological) Show Details
    Description
    (MP9202) Prior authorization through the Medical Affairs Division is required to determine whether an abortion will be covered on the grounds of medical necessity.
    Last Updated
    2/13/2014
  • /app/files/public/4593/pdf-medicalpolicies-9023Acne.pdf Acne Show Details
    Description
    (MP9023) Dean Health Plan's Medical Policy on the treatment of Acne. (Related: dermabrasion, collagen, hyperbaric, photodynamic therapy, acne vulgaris, cystic acne, Dermatology)
    Last Updated
    2/13/2014
  • /app/files/public/4690/pdf-medicalpolicies-9300Agalsidase.pdf Agalsidase (FABRAZYME) Show Details
    Description
    Agalsidase (FABRAZYME) MP9300 is administered every 2 weeks in the physician’s office is considered medically appropriate for the treatment of Fabry’s Disease and requires prior authorization.
    Last Updated
    9/23/2015
  • /app/files/public/6445/DHP9446_AAT.pdf Alpha 1 Antitrypsin Inhibitors Show Details
    Description
    (MP9446) Alpha 1 Antitrypsin Inhibitors require prior authorization and is considered medically appropriate when the criteria listed in the medical policy are met.
    Last Updated
    9/24/2015
  • /app/files/public/4726/pdf-medicalpolicies-9355AminoAcidBasedFormulas.pdf Amino Acid-Based Formulas (Neocate, Elecare, Nutramigen AA) Show Details
    Description
    (MP9355) Amino acid based formulas require prior authorization through the Medical Affairs Division. (Related: Eosinophilic esophagitis, atopy or eczema, food allergy, formula protein intolerance, cystic fibrosis, fatty acid, metabolic or malabsorption disorders)
    Last Updated
    2/13/2014
  • /app/files/public/4749/pdf-medicalpolicies-9382AngioplastyofCarotid-and-Vertebral-arteries.pdf Angioplasty and Stenting of Extra-Cranial and Intra-Cranial Arteries Show Details
    Description
    (MP9382) Percutaneous transluminal angioplasty of the extra-cranial carotid arteries and vertebral arteries, with or without stent implantation and embolic protection, requires prior authorization through the Medical Affairs Division. (Related: stenosis, intracranial.)
    Last Updated
    2/13/2014
  • /app/files/public/7854/Aripiprazole-Abilfy-Maintena-MP9456.pdf Aripiprazole (ABILIFY MAINTENA) Show Details
    Description
    Aripiprazole (ABILIFY MAINTENA) MP9456 requires prior authorization. It used in the treatment of schizophrenia and new starts must be prescribed by a Psychiatrist.
    Last Updated
    3/2/2015
  • /app/files/public/4735/pdf-medicalpolicies-9364Dynesys.pdf Artificial Intervertebral Discs Show Details
    Description
    (MP9364) Artificial cervical disc systems require prior authorization through the Medical Affairs Division and are considered medically appropriate when all of the criteria in the medical policy are met. (related: cervical surgery, intractable radiculopathy, myelopathy, facet disease, sagittal balance)
    Last Updated
    2/13/2014
  • /app/files/public/4589/pdf-medicalpolicies-9016Coch.pdf Auditory Brain Stem and Cochlear Implants Show Details
    Description
    (MP9016) Cochlear implant requests for members with bilateral sensorineural hearing impairment must meet criteria described in policy. (Related: Ossification, Auditory brain stem implant, bilateral resection of neurofibromas.)
    Last Updated
    2/13/2014