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.
- 5.01.022 Valcyte (valganciclovir)
- 5.01.023 Ketoconazole
- 5.01.031 Sivextro (tedizolid)
- 5.01.034 Xifaxan (rifaximin)
- 5.01.035 Cresemba (isavuconazonium)
- 5.01.038 Daraprim (pyrimethamine)
- 5.01.041 Hepatitis C
- 5.01.042 Anthelmintic Drugs
- 5.01.043 Prevymis (letermovir)
- 5.01.044 Vfend (voriconazole)
- 5.01.045 Trogarzo (ibalizumab-uiyk)
- 5.01.046 Xepi (ozenoxacin)
- 5.01.047 Pegasys Pegintron Ribavirin
- 5.01.048 Arikayce (amikacin liposome inhalation suspension)
- 5.01.049 Xofluza (baloxavir marboxil)
- 5.01.050 Aemcolo (rifamycin)
- 5.01.052 Noxafil (posaconazole)
- 5.01.053 Nuzyra (omadacycline)
- 5.01.054 Baxdela (delafloxacin)
- 5.01.055 Xenleta (lefamulin)
- 5.01.056 Baraclude (entecavir) tablets
- 5.01.057 Hepsera (adefovir)
- 5.01.058 Cabenuva (cabotegravir rilpivirine)
- 5.01.059 Tembexa (brincidofovir)
- 5.01.071 Livtencity (maribavir)
- 5.01.072 Brexafemme (ibrexfungerp)
- 5.01.074 COVID-19 Oral Antiviral Agents
- 5.01.075 Apretude (cabotegravir extended-release injectable suspension)
- 5.01.076 Vivjoa (oteseconazole)
- 5.01.077 Sunlenca (lenacapavir)
- 5.20.001 Atgam (lymphocyte immune globulin, anti-thymocyte globulin [equine])
- 5.20.002 GamaSTAN S/D (IGIM)
- 5.20.003 IVIG (intravenous immunoglobulin)
- 5.20.004 Synagis (palivizumab)
- 5.20.005 Ragwitek (short ragweed pollen allergen extract)
- 5.20.006 Oralair (mixed pollens allergen extract)
- 5.20.007 Grastek (timothy grass pollen allergen extract)
- 5.20.008 SCIG Immune Globulin (subcutaneous immunoglobulin)
- 5.20.010 Sylvant (siltuximab)
- 5.20.011 Odactra (house dust mite allergen extract)
- 5.20.012 Palforzia [Peanut (Arachis hypoqaea) Allergen Powder-dnfp]
- 5.20.013 Ryplazim (plasminogen, human-tvmh)
- 5.20.014 Veopoz (pozelimab-bbfg)
- 5.20.015 Beyfortus (nirsevimab-alip)
- 5.21.001 Actimmune (interferon gamma-1B)
- 5.21.002 Alferon N (interferon alfa-N3)
- 5.21.003 Arzerra (ofatumumab)
- 5.21.004 Bevacizumab
- 5.21.005 Venclexta (venetoclax)
- 5.21.006 Trastuzumab