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.

Policy set dated July 13, 2026Posted 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.

Find a policy

Commercial

Commercial policies

91 policies across 26 categories, policy set dated July 13, 2026.

Alpha1-Proteinase Inhibitors

Alpha1-Proteinase Inhibitor Products UM Medical PolicyPDF · 194 KB

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

Immune Globulin

Immunologicals

Inflammatory Conditions

Oncology (Injectable - CD20-Directed Antibody)

Rituxan Hycela UM Medical PolicyPDF · 190 KB

Oncology (Injectable - HER2 Antagonist)

Oncology (Injectable - Programmed Death Receptor-1)

Oncology (Injectable)

Oncology (Intravesical)

Ophthalmology

Repository Corticotropin

Acthar Gel UM Medical PolicyPDF · 191 KB

Rituximab Products

Rituximab Intravenous Products UM Medical PolicyPDF · 551 KB

Spinal Muscular Atrophy

Uplizna

Uplizna UM Medical PolicyPDF · 236 KB

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.