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.
- 5.90.065 Izervay (avacincaptad pegol)
- 5.90.066 Xdemvy (lotilaner) ophthalmic solution
- 5.90.067 Bimzelx (bimekizumab-bkzx)
- 5.90.068 Omvoh (mirikizumab-mrkz)
- 5.90.069 Miebo (perfluorohexyloctane ophthalmic solution)
- 5.90.070 Filsuvez (birch triterpenes) topical gel
- 5.99.001 Benlysta (belimumab)
- 5.99.002 Exjade Jadenu (deferasirox)
- 5.99.006 Xiaflex (collagenase clostridium histolyticum)
- 5.99.008 Diabetes Test Strips
- 5.99.009 Ferriprox (deferiprone)
- 5.99.010 Compound High Dollar Limit
- 5.99.011 Corticosteroid Powders
- 5.99.014 Continuous Glucose Monitors (CGM) and Supplies
- 5.99.016 Disposable Insulin Delivery Devices
- 5.99.018 Uplizna (inebilizumab-cdon)
- 5.99.019 Enspryng (satralizumab-mwge)
- 5.99.020 Zokinvy (lonafarnib)
- 5.99.021 Lupkynis (voclosporin)
- 5.99.022 LifEMS Naloxone (naloxone convenience kit)
- 5.99.023 Saphnelo (anifrolumab-fnia)
- 5.99.024 Zortress (everolimus)
- 5.99.025 Condoms
- 5.99.026 Vyvgart (efgartigimod alfa-fcab)
- 5.99.027 Weight Loss Medications
- 5.99.029 Zynteglo (betibeglogene autotemcel)
- 6.01.01 Bone Mineral Density Studies
- 6.01.03 Computed Tomography to Detect Coronary Artery Calcification
- 6.01.06 Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography
- 6.01.10 Stereotactic Radiosurgery and Stereotactic Body Radiotherapy
- 6.01.12 Thermography
- 6.01.20 Cardiac Applications of Positron Emission Tomography Scanning
- 6.01.24 Magnetic Resonance Spectroscopy
- 6.01.25 Minimally Invasive Approaches to Vertebral Fractures and Osteolytic Lesions of the Spine
- 6.01.26 Oncologic Applications of Positron Emission Tomography Scanning (Genitourinary)
- 6.01.29 Magnetic Resonance Imaging for Detection and Diagnosis of Breast Cancer
- 6.01.32 Virtual Colonoscopy/Computed Tomography Colonography
- 6.01.33 Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders
- 6.01.40 Whole Body Dual X-Ray Absorptiometry to Determine Body Composition
- 6.01.43 Contrast-Enhanced Computed Tomographic Angiography for Coronary Artery Evaluation
- 6.01.44 Vertebral Fracture Assessment with Densitometry
- 6.01.49 Computed Tomography Perfusion Imaging of the Brain
- 6.01.51 Interim Positron Emission Tomography Scanning in Oncology to Detect Early Response During Treatment
- 6.01.55 Selected Positron Emission Tomography Technologies for Evaluation of Alzheimer Disease
- 6.01.56 Myocardial Sympathetic Innervation Imaging in Patients With Heart Failure
- 6.01.59 Coronary Computed Tomography Angiography With Selective Noninvasive Fractional Flow Reserve
- 6.01.61 Oncologic Applications of Positron Emission Tomography Scanning (Gastrointestinal and Pancreatic)
- 6.01.62 Oncologic Applications of Positron Emission Tomography Scanning (Breast and Gynecologic)
- 6.01.63 Oncologic Applications of Positron Emission Tomography Scanning (Bone and Sarcoma)
- 6.01.64 Oncologic Applications of Positron Emission Tomography Scanning (Hematologic)