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.
- 5.21.110 Braftovi (encorafenib)
- 5.21.111 Mektovi (binimetinib)
- 5.21.112 Tibsovo (ivosidenib)
- 5.21.113 Azedra (iobenguane I 131)
- 5.21.114 Poteligeo (mogamulizumab-kpkc)
- 5.21.116 Copiktra (duvelisib)
- 5.21.117 Vizimpro (dacomitinib)
- 5.21.118 Libtayo (cemiplimab-rwlc)
- 5.21.119 Talzenna (talazoparib)
- 5.21.120 Lorbrena (lorlatinib)
- 5.21.121 Daurismo (glasdegib)
- 5.21.122 Vitrakvi (larotrectinib)
- 5.21.123 Xospata (gilteritinib)
- 5.21.124 Elzonris (tagraxofusp-erzs)
- 5.21.125 Asparlas (calaspargase pegol-mknl)
- 5.21.126 Herceptin Hylecta (trastuzumab and hyaluronidase-oysk)
- 5.21.127 Balversa (erdafitinib)
- 5.21.128 Piqray (alpelisib)
- 5.21.129 Polivy (polatuzumab vedotin-piiq)
- 5.21.130 Xpovio (selinexor)
- 5.21.131 Nubeqa (darolutamide)
- 5.21.132 Turalio (pexidartinib)
- 5.21.133 Inrebic (fedratinib)
- 5.21.134 Rozlytrek (entrectinib)
- 5.21.135 Oncaspar (pegaspargase)
- 5.21.136 Brukinsa (zanubrutinib)
- 5.21.137 Padcev (enfortumab vedotin-ejfv)
- 5.21.138 Enhertu (fam-trastuzumab deruxtecan-nxki)
- 5.21.139 Ayvakit (avapritinib)
- 5.21.140 Tazverik (tazemetostat)
- 5.21.141 Sarclisa (isatuximab-irfc)
- 5.21.142 Koselugo (selumetinib)
- 5.21.143 Tukysa (tucatinib)
- 5.21.144 Pemazyre (pemigatinib)
- 5.21.145 Trodelvy (sacituzumab govitecan-hziy)
- 5.21.146 Tabrecta (capmatinib)
- 5.21.147 Darzalex Faspro (daratumumab and hyaluronidase-fihj)
- 5.21.148 Retevmo (selpercatinib)
- 5.21.149 Qinlock (ripretinib)
- 5.21.150 Jelmyto
- 5.21.151 Zevalin (ibritumomab tiuxetan)
- 5.21.152 Zepzelca (lurbinectedin)
- 5.21.153 Phesgo (pertuzumab, trastuzumab, hyaluronidase-zzxf)
- 5.21.154 Inqovi (decitabine cedazuridine)
- 5.21.155 Tecartus (brexucabtagene autoleucel)
- 5.21.156 Monjuvi (tafasitamab-cxix)
- 5.21.157 Blenrep (belantamab mafodotin-blmf)
- 5.21.158 Faslodex (fulvestrant)
- 5.21.159 Temodar (temozolomide) capsules
- 5.21.160 Xeloda (capecitabine)