Medical Policies
Policies that are included in the FEP Medical Policy Manual.
The policies contained in the FEP Medical Policy Manual are developed to assist in administering contractual benefits and do not constitute medical advice. They are not intended to replace or substitute for the independent medical judgment of a practitioner or other health care professional in the treatment of an individual member. The Blue Cross and Blue Shield Association does not intend by the FEP Medical Policy Manual, or by any particular medical policy, to recommend, advocate, encourage or discourage any particular medical technologies. Medical decisions relative to medical technologies are to be made strictly by members/patients in consultation with their health care providers. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that the Blue Cross and Blue Shield Service Benefit Plan covers (or pays for) this service or supply for a particular member.
- 5.50.001 Proton Pump Inhibitors
- 5.50.002 Infliximab
- 5.50.003 Gattex (teduglutide)
- 5.50.005 NK1 Antagonists
- 5.50.006 Opioid Antagonist Drug Class
- 5.50.007 Viberzi (eluxadoline)
- 5.50.009 Cholbam (cholic acid)
- 5.50.010 Ocaliva (obeticholic acid)
- 5.50.011 Cimzia (certolizumab pegol)
- 5.50.012 Entyvio (vedolizumab)
- 5.50.013 Trulance (plecanatide)
- 5.50.014 Xermelo (telotristat ethyl)
- 5.50.015 5-HT3 Antagonists
- 5.50.016 Doxylamine Pyridoxine
- 5.50.017 Cannabinoids
- 5.50.021 H. pylori Infection Agents
- 5.50.022 Amitiza (lubiprostone)
- 5.50.023 Linzess (linaclotide)
- 5.50.024 Motegrity (prucalopride)
- 5.50.026 Ibsrela (tenapanor)
- 5.50.028 Barhemsys (amisulpride)
- 5.50.029 Mytesi (crofelemer)
- 5.50.030 Chenodal (chenodiol)
- 5.50.031 Bylvay (odevixibat)
- 5.50.032 Livmarli (maralixibat)
- 5.50.033 Dartisla ODT (glycopyrrolate)
- 5.50.034 Rebyota
- 5.50.035 Vowst (fecal microbiota, live-brpk)
- 5.50.036 Vibrant System
- 5.50.037 Velsipity (etrasimod)
- 5.50.038 Voquezna (vonoprazan)
- 5.50.039 Zymfentra (infliximab-dyyb) injection, for subcutaneous use
- 5.50.040 Iqirvo (elafibranor)
- 5.55.001 Procysbi (cysteamine bitartrate)
- 5.55.002 Oxlumo (lumasiran)
- 5.55.003 Tiopronin
- 5.55.004 Filspari (sparsentan)
- 5.55.005 Rivfloza (nedosiran)
- 5.60.001 Tecfidera Bafiertam Vumerity
- 5.60.002 Ampyra (dalfampridine)
- 5.60.003 Nuplazid (pimavanserin)
- 5.60.004 MS Injectable Drugs
- 5.60.005 Xyrem (sodium oxybate)
- 5.60.006 Orexin Antagonists
- 5.60.007 Rozerem (ramelteon)
- 5.60.008 Gilenya Tascenso ODT
- 5.60.009 Aubagio (teriflunomide)
- 5.60.010 Hetlioz (tasimelteon)
- 5.60.011 Sedative Hypnotics
- 5.60.012 Xenazine (tetrabenazine)