Advancedhealth Coverage Criteria
Latest Advancedhealth coverage criteria updates12
- Coverage CriteriaClinical/Medical PolicyButalbital-Containing Products Drug Use CriteriaThis policy governs prior authorization and coverage criteria for butalbital-containing products used by Oregon Health Plan members for headaches. It applies to requests for acute treatment of chronic migraine, tension-type headache, or acute migraine, with age, pregnancy, medication-overuse, severity, and prior-treatment requirements.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyErythropoiesis-Stimulating Agent (ESA) Coverage GuidelineThis guideline governs coverage of erythropoiesis-stimulating agents for anemia associated with cancer chemotherapy, myelodysplasia, HIV/AIDS, and chronic renal failure. Coverage depends on hemoglobin or hematocrit thresholds, condition-specific requirements, reassessment, treatment response, and hemoglobin limits.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyGeneral Drug Use Criteria for Prior AuthorizationsEstablishes general coverage and prior authorization requirements for non-formulary medications and formulary medications requiring pre-approval when no drug-specific criteria exist for Advanced Health Oregon Health Plan members, including initial and renewal requests.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyHepatitis C Direct-Acting Antiviral TherapyCoverage and prior authorization for direct-acting antiviral regimens used to treat hepatitis C infection in adults, adolescents, and children, based on genotype, prior treatment, cirrhosis status, age, and safety considerations.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyMedications for Weight Management Drug Use CriteriaEstablishes initial and renewal coverage criteria for FDA-approved weight management medications and supported compendia use for Advanced Health Oregon Health Plan members.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyMyrbetriq (mirabegron) Coverage CriteriaThis policy governs initial and renewal authorization for Myrbetriq and mirabegron for Advanced Health members under the Oregon Health Plan. Coverage requires treatment of a funded condition or qualifying comorbid condition and generally requires trials of at least two lower-cost alternatives.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyNebulized Medications Drug Use CriteriaThis policy governs pharmacy-benefit coverage of FDA-approved nebulized medications and establishes initial and renewal authorization requirements, including nebulizer access, appropriate diagnosis, medical necessity, and assessment of alternative inhaler delivery.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyNon-Preferred Inhaler Drug Use CriteriaThis policy governs prior authorization and medical-necessity review for non-preferred inhalers used for funded asthma, COPD, or qualifying comorbid conditions. It requires an FDA-approved indication and adequate trial and failure of a preferred inhaler, with separate renewal durations for asthma and COPD.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyOmnipod Drug Use CriteriaThis policy governs coverage decisions for Omnipod use in members with type 1 or type 2 diabetes and specifies diagnostic, clinical, provider, education, device-necessity, and compatible CGM requirements.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyTecfidera (dimethyl fumarate) Coverage CriteriaThis policy governs prior authorization and renewal coverage for oral dimethyl fumarate used to treat relapsing forms of multiple sclerosis in adult members. It establishes prescriber, indication, safety-monitoring, concurrent-therapy, dosing, and continuation requirements.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyTobacco Cessation Drug CriteriaThis policy governs prior authorization and coverage criteria for nicotine inhalers and nicotine nasal sprays for Advanced Health members. It also identifies tobacco cessation medications available on formulary without prior authorization for up to two quit attempts per year.All advancedhealth updates
- Coverage CriteriaClinical/Medical PolicyVoquezna (vonoprazan) Coverage CriteriaThis policy governs prior authorization for Voquezna in adults with endoscopy-confirmed erosive esophagitis or non-erosive GERD with heartburn symptoms. It requires safety screening and, for GERD indications, an inadequate response or intolerance to an 8-week formulary proton pump inhibitor trial.All advancedhealth updates
1–12 of 12
1 / 1
Tool Description
Search Advancedhealth coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.