Teplizumab-mzwv

This policy covers use of teplizumab‑mzwv (Tzield) when all specified medical necessity criteria are met to delay progression to clinical type 1 diabetes. Coverage is limited to patients aged ≥8 years with Stage 2 type 1 diabetes (≥2 positive islet autoantibodies and dysglycemia without overt hyperglycemia), requires absence of clinical features of type 2 diabetes, acceptable baseline labs and no active/acute EBV/CMV or other serious infections, is limited to a single 14‑dose course, and remains subject to the member’s benefit plan and applicable state/contract exclusions.

"Coverage for services and supplies is determined by the member's benefit plan, summary plan description, or contract."

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