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.
- 2.04.152 Maternal Serum Biomarkers for Prediction of Adverse Obstetric Outcomes
- 2.04.153 Tumor Informed Circulating Tumor DNA Testing for Cancer Management
- 2.04.154 Germline Genetic Testing for Hereditary Diffuse Gastric Cancer (CDH1, CTNNA1)
- 2.04.155 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Prostate Cancer (BRCA1/2, Homologous Recombination Repair Gene Alterations, NTRK Gene Fusion)
- 2.04.156 Germline and Somatic Biomarker Testing (Including Liquid Biopsy) for Targeted Treatment in Ovarian Cancer (BRCA1, BRCA2, Homologous Recombination Deficiency, NTRK)
- 2.04.157 Somatic Biomarker Testing for Immune Checkpoint Inhibitor Therapy (BRAF, MSI/MMR, PD-L1, TMB)
- 2.04.159 Laboratory Testing Investigational Services
- 3.01.03 Quantitative Electroencephalography as a Diagnostic Aid for Attention-Deficit/Hyperactivity Disorder
- 3.03.01 Digital Health Technologies: Diagnostic Applications
- 3.03.02 Digital Health Technologies: Therapeutic Applications
- 3.03.03 Digital Health Therapies for Attention Deficit/Hyperactivity Disorder
- 4.01.04 Endometrial Ablation
- 4.01.10 Fetal Surgery for Prenatally Diagnosed Malformations
- 4.01.11 Occlusion of Uterine Arteries Using Transcatheter Embolization
- 4.01.18 Ovarian and Internal Iliac Vein Embolization as a Treatment of Pelvic Congestion Syndrome
- 4.01.19 Laparoscopic, Percutaneous, and Transcervical Techniques for Uterine Fibroid Myolysis
- 4.01.21 Noninvasive Prenatal Screening for Fetal Aneuploidies, Microdeletions, Single- Gene Disorders, and Twin Zygosity Using Cell-Free Fetal DNA
- 5.01.001 Intron A Hepatitis B
- 5.01.02 Pegasys Hepatitis B
- 5.01.005 Intron A Hepatitis C
- 5.01.006 Intron A Ribavirin
- 5.01.07 Pegasys Hepatitis C
- 5.01.08 Pegasys Ribavirin
- 5.01.11 PegIntron Hepatitis C
- 5.01.12 PegIntron Ribavirin
- 5.01.015 Injectable Antibiotics
- 5.01.017 Relenza (zanamivir)
- 5.01.018 Itraconazole
- 5.01.019 Tamiflu (oseltamivir)
- 5.01.020 Zyvox (linezolid)
- 5.01.022 Valcyte (valganciclovir)
- 5.01.023 Ketoconazole
- 5.01.24 Sovaldi Pegasys PegIntron Ribavirin
- 5.01.25 Sovaldi Pegasys Ribavirin
- 5.01.27 Olysio PegIntron Ribavirin
- 5.01.28 Olysio Pegasys Ribavirin
- 5.01.29 Sovaldi Olysio
- 5.01.30 Sovaldi Olysio Ribavirin
- 5.01.031 Sivextro (tedizolid)
- 5.01.034 Xifaxan (rifaximin)
- 5.01.035 Cresemba (isavuconazonium)
- 5.01.37 Technivie
- 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