Our policy bulletins communicate our medical necessity criteria and coverage, claim reimbursement rules and billing guidelines and drug positions for services administered to Jefferson Health Plans members. Recent policy additions and updates include the following:
Medical Necessity Policies:
MN.004.C New Technology: 2026 Annual review. Revisions to policy guidelines. Additions to Definition section.
MN.005.D Experimental and Investigational Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED): 2026 Annual Review. No changes to this policy version.
MN.006.I Cosmetic and Reconstructive Services: 2026 Annual Review. Revisions to coding table.
Claims Payment Policies:
RB.001.D Ambulance Ground Mileage: 2026 Annual review. No changes to this policy version.
RB.024.C Professional Telehealth Services (Medicaid & CHIP): 2026 Annual Review. Policy statement revised to include asynchronous interaction. Codes removed. References updated.
RB.027.B Tobacco Cessation Program: 2026 Reissue. Additions to policy statement and guidelines, ICD-10 code table removed. References updated.
RB.044.A Urine Drug Testing: New policy effective 4/9/2026
RB.046.A Home Infusion Billing Requirements: New policy effective 6/14/2026
RB.047.A STI Laboratory Testing Reimbursement: New policy effective 5/14/2026
RB.048.A Readmissions - Medicaid and CHIP: New policy effective 6/11/2026
RB.051.A Community Health Worker Services : New policy effective 6/26/2026
Drug Policies:
DR.004.F Spinraza: 2026 Annual Review. Revisions to Prior authorization criteria, Renewal criteria, ICD 10 codes. References updated.
DR.005.F ZOLGENSMA® (onasemnogene abeparvovec-xioi) : 2026 Annual Review. Revisions made to FDA approved indications, Prior Authorization Criteria, Dosage and Administration, Risk factors/Side effects Monitoring and Black Box Warning Sections. References updated.
DR.007.E Adakveo® (crizanlizumab-tcma) : 2026 Annual Review. Revisions to Prior authorization criteria and Renewal Criteria. References updated.
DR.008.D Sandostatin® LAR Depot (octreotide acetate) : 2026 Annual Review. Revisions made to Prior Authorization Criteria, Renewal Criteria, Dosage & Administration, Risk Factors/Side Effects, Monitoring, Clinical Evidence and Background Sections. References updated.
DR.015.B ROCTAVIAN™ (valoctocogene roxaparvovec-rvox) : 2026 Annual Review. Revisions made to dosage and administration/risk factors and side effects/monitoring.
DR.017.C Adstiladrin® (Nadofaragene firadenovec-vncg) : 2026. Annual review. Revisions to Prior Authorization Criteria, Renewal Criteria, Dosage and Administration, Safety and Monitoring Sections. References updated.
DR.018.C Viltepso® (Viltolarsen): 2026 Annual Review. Revisions to Prior Authorization Criteria, renewal Criteria, Safety and Monitoring, Dosage and Administration Sections. References Updated.
DR.019.C Hemgenix® (Etranacogene dezaparvovec-drlb) : 2026 Annual Review. Revisions to Prior Authorization Criteria, Renewal Criteria, Safety and Monitoring, and Dosage and Administration Sections. References Updated.