Medical Policies
Medical policies.
Utilization management medical policies posted for use by participating organizations and their downstream entities. Each policy is provided as a PDF, exactly as issued.
Latest update posted October 26, 2026Initial library posted July 29, 2026
Policies are organized by therapeutic category. Commercial policies are listed first, followed by Medicare-specific policies grouped by the coverage authority they follow.
Medicare Advantage
Where a Medicare-specific policy exists, it applies to Medicare Advantage business. Where none exists, the commercial policy applies.
Commercial
Commercial policies
107 policies across 33 categories.
Alpha1-Proteinase Inhibitors
Alzheimer's Disease
Amyloidosis
Bone Modifiers
Botulinum Toxins
Colony Stimulating Factors
Complement Inhibitors
Dermatology
Enzyme Replacement Therapy
Erythropoiesis-Stimulating Agents
Gaucher Disease
Gonadotropin-Releasing Hormone Agonists
Hematology
Hemophilia
- Altuviiio UM Medical PolicyPDF · 155 KB
- Factor VIII Products UM Medical PolicyPDF · 209 KB
- Gene Therapy - Hemgenix UM Medical PolicyPDF · 252 KB
- Gene Therapy - Roctavian UM Medical PolicyPDF · 184 KB
- Non-Factor Routine Prophylaxis Products Hemlibra UM Medical PolicyPDF · 193 KB
- Non-Factor Routine Prophylaxis Products Hympavzi PA PolicyPDF · 174 KB
Hyaluronic Acid Derivatives
Hyperlipidemia
Immunologicals
Inflammatory Conditions
- Cimzia UM Medical PolicyPDF · 360 KB
- Cosentyx Intravenous UM Medical PolicyPDF · 258 KB
- Entyvio Intravenous UM Medical PolicyPDF · 280 KB
- Etanercept Products PA PolicyPDF · 382 KB
- Ilaris UM Medical PolicyPDF · 295 KB
- Ilumya UM Medical PolicyPDF · 205 KB
- Infliximab IV Products UM Medical PolicyPDF · 541 KB
- Omvoh Intravenous UM Medical PolicyPDF · 226 KB
- Orencia Intravenous UM Medical PolicyPDF · 304 KB
- Simponi Aria UM Medical PolicyPDF · 264 KB
- Skyrizi Intravenous UM Medical PolicyPDF · 208 KB
- Tocilizumab IV Products UM Medical PolicyPDF · 484 KB
- Tocilizumab SubQ Products PA PolicyPDF · 326 KB
- Tremfya Intravenous UM Medical PolicyPDF · 229 KB
- Tremfya Subcutaneous PA PolicyPDF · 260 KB
- Ustekinumab IV Products UM Medical PolicyPDF · 250 KB
- Ustekinumab SubQ Products PA Policy with DosingPDF · 298 KB
- Zymfentra PA PolicyPDF · 211 KB
Multiple Sclerosis
Multiple Sclerosis and Crohn's Disease
Neurology
Oncology (Injectable - CAR-T)
Oncology (Injectable - CD20-Directed Antibody)
Oncology (Injectable - HER2 Antagonist)
Oncology (Injectable - Programmed Death Receptor-1)
Oncology (Injectable)
Oncology (Intravesical)
Ophthalmology
- Gene Therapy - Encelto UM Medical PolicyPDF · 149 KB
- Vascular Endothelial Growth Factor Inhibitors - Lytenava UM Medical PolicyPDF · 134 KB
- VEGF Inhibitors - Aflibercept Products UM Medical PolicyPDF · 217 KB
- VEGF Inhibitors - Beovu UM Medical PolicyPDF · 137 KB
- VEGF Inhibitors - Ranibizumab Products UM Medical PolicyPDF · 159 KB
- VEGF Inhibitors - Susvimo UM Medical PolicyPDF · 122 KB
- VEGF Inhibitors - Vabysmo UM Medical PolicyPDF · 146 KB
Repository Corticotropin
Rituximab Products
Spinal Muscular Atrophy
Medicare
Medicare-specific policies
16 policies, grouped by the national coverage determination or Medicare contractor they follow. Each row shows the policy date from the issued document.
NCD 110.10
NCD 110.21
NCD 110.24
- Oncology (Injectable - CAR-T) - Aucatzyl MA Policy12.3.25 · PDF · 182 KB
- Oncology (Injectable - CART) - Breyanzi MA Policy2.9.26 · PDF · 246 KB
- Oncology (Injectable - CART) - Kymriah MA Policy4.6.26 · PDF · 258 KB
- Oncology (Injectable - CART) - Tecartus MA Policy9.26.25 · PDF · 192 KB
- Oncology (Injectable - CART) - Yescarta MA Policy4.20.26 · PDF · 246 KB
Noridian JE, JF
- Botulinum Toxins - Botox MA Policy6.23.26 · PDF · 386 KB
- Botulinum Toxins - Daxxify MA Policy6.23.26 · PDF · 169 KB
- Botulinum Toxins - Dysport MA Policy6.23.26 · PDF · 243 KB
- Botulinum Toxins - Myobloc MA Policy6.23.26 · PDF · 195 KB
- Botulinum Toxins - Xeomin MA Policy6.23.26 · PDF · 200 KB
- Immune Globulin - Intravenous MA CC Policy6.11.26 · PDF · 768 KB