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.
- 5.60.013 Tysabri (natalizumab)
- 5.60.014 Provigil Nuvigil
- 5.60.015 Austedo (deutetrabenazine)
- 5.60.023 Lemtrada (alemtuzumab)
- 5.60.024 Amphetamines
- 5.60.025 Methylphenidate Dexmethylphenidate
- 5.60.026 Zyprexa Relprevv (olanzapine)
- 5.60.027 Nuedexta (dextromethorphan quinidine)
- 5.60.028 Ocrevus (ocrelizumab)
- 5.60.029 Ingrezza (valbenazine)
- 5.60.030 Lucemyra (lofexidine)
- 5.60.031 Inbrija (levodopa inhalation powder)
- 5.60.033 Spravato (esketamine nasal spray)
- 5.60.034 Mayzent (siponimod)
- 5.60.035 Mavenclad (cladribine)
- 5.60.036 Sunosi (solriamfetol)
- 5.60.037 Zulresso (brexanolone)
- 5.60.038 Wakix (pitolisant)
- 5.60.039 Nourianz (istradefylline)
- 5.60.040 Abilify Mycite (aripiprazole with sensor)
- 5.60.041 Nayzilam (midazolam nasal spray)
- 5.60.042 Tasmar (tolcapone)
- 5.60.043 Valtoco (diazepam nasal spray)
- 5.60.044 Zeposia (ozanimod)
- 5.60.045 Fintepla (fenfluramine)
- 5.60.046 Xywav (calcium, magnesium, potassium, sodium oxybates)
- 5.60.047 Kesimpta (ofatumumab)
- 5.60.048 Imcivree (setmelanotide)
- 5.60.049 Ponvory (ponesimod)
- 5.60.050 Qelbree (viloxazine)
- 5.60.051 Apomorphine
- 5.60.052 Aduhelm (aducanumab-avwa)
- 5.60.053 Korsuva (difelikefalin)
- 5.60.054 Lybalvi (olanzapine and samidorphan)
- 5.60.055 Skysona (elivaldogene autotemcel)
- 5.60.056 Leqembi
- 5.60.057 Briumvi (ublituximab-xiiy)
- 5.60.058 Auvelity (dextromethorphan and bupropion)
- 5.60.059 Lumryz (sodium oxybate)
- 5.60.061 Modafinil powder
- 5.60.062 Libervant (diazepam buccal film)
- 5.70.001 Abstral (fentanyl sublingual)
- 5.70.002 Actiq (oral transmucosal fentanyl citrate)
- 5.70.003 5-HT1 Agonists (Triptans)
- 5.70.004 Arcalyst (rilonacept)
- 5.70.006 Celebrex (celecoxib)
- 5.70.007 Fentora (fentanyl buccal)
- 5.70.009 Ilaris (canakinumab)
- 5.70.012 Actemra (tocilizumab)
- 5.70.013 Ketalar (ketamine)