Agency For Health Care Administration Coverage Criteria
- Agency For Health Care Administration prior authorization
- Agency For Health Care Administration timely filing
- All Agency For Health Care Administration policy updates
Latest Agency For Health Care Administration coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01SUNOSI (solriamfetol) Coverage CriteriaPrior authorization for SUNOSI (solriamfetol) in adults with narcolepsy or obstructive sleep apnea and associated excessive daytime sleepiness, including initial authorization, continuation, documentation, dosing, and authorization duration requirements.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyABECMA (idecabtagene vicleucel) Coverage and Prior AuthorizationThis policy governs prior authorization and administration of ABECMA (idecabtagene vicleucel) for adults with relapsed or refractory multiple myeloma in hospital inpatient or outpatient settings.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyARIKAYCE Prior Authorization CriteriaPrior authorization coverage criteria for ARIKAYCE (amikacin liposome inhalation suspension) in adults with refractory Mycobacterium avium complex lung disease.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyAbilify MyCite Prior Authorization CriteriaThis policy governs prior authorization for Abilify MyCite for eligible Florida Medicaid fee-for-service members and establishes clinical criteria, documentation requirements, alternate approval criteria, and a three-month authorization period.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyAmlodipine (Norliqva and Katerzia) Oral Solution/Suspension Coverage CriteriaThis policy governs prior authorization for Norliqva (amlodipine) oral solution and Katerzia (amlodipine) oral suspension for patients age 6 years or older with hypertension or specified coronary artery disease indications, subject to preferred-agent trial requirements and continuation criteria.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBREYANZI (lisocabtagene maraleucel) Coverage CriteriaThis policy governs prior authorization for BREYANZI (lisocabtagene maraleucel) for adult patients with specified large B-cell lymphomas. It establishes eligibility criteria, authorization duration, dosing information, and administration through a REMS-certified healthcare facility.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBehavioral Health Community Support Services Coverage PolicyThis policy governs coverage of behavioral health community support services for eligible Florida Medicaid recipients, including recipients enrolled in Florida Medicaid managed care plans. It establishes recipient eligibility, provider obligations, coverage criteria, copayment requirements, and coordination with other Florida Medicaid policies.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBenlysta (belimumab) Prior Authorization CriteriaThis policy governs prior authorization for Benlysta (belimumab) for active, autoantibody-positive systemic lupus erythematosus and active lupus nephritis, and applies to providers requesting coverage through the Agency for Health Care Administration.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBile Salts AgentsThis policy governs Medicaid fee-for-service prior authorization for preferred and non-preferred bile salts agents, including product-specific clinical criteria, documentation, laboratory monitoring, and authorization duration.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBrexafemme (ibrexafungerp) Coverage CriteriaThis pharmacy policy establishes prior authorization criteria for Brexafemme (ibrexafungerp) for post-menarchal females at least 12 years of age with vulvovaginal candidiasis. Authorization is provided per prescription when the specified pregnancy-testing and fluconazole trial requirements are met.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyBrinsupri (brensocatib) Coverage CriteriaThis policy governs prior authorization for Brinsupri (brensocatib) tablets for Medicaid beneficiaries with non-cystic fibrosis bronchiectasis, including initial and continuation therapy criteria, authorization durations, and dosing information.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCamzyos (mavacamten) Coverage CriteriaThis policy governs prior authorization and continuation criteria for Camzyos (mavacamten) in adults with symptomatic obstructive hypertrophic cardiomyopathy and requires participation in the Camzyos REMS program.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCarbaglu (carglumic acid) Coverage CriteriaThis policy governs prior authorization for Carbaglu (carglumic acid) for patients with specified causes of acute or chronic hyperammonemia. It applies to providers submitting medical records and laboratory documentation for initial or continued therapy.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCerdelga (eliglustat) Prior Authorization CriteriaThis policy establishes prior authorization criteria for Cerdelga (eliglustat) for adults with Gaucher disease Type I. It also defines continuation-of-therapy requirements and an authorization duration of up to one year.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCerezyme (imiglucerase) Prior Authorization CriteriaThis policy establishes prior authorization criteria for Cerezyme (imiglucerase) for patients with Type I or Type 3 Gaucher disease, including initial and continuation coverage, documentation, specialist prescribing, and authorization duration.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyChorionic Gonadotropin (Pregnyl® and Novarel®)This policy governs prior authorization and coverage criteria for Pregnyl and Novarel (chorionic gonadotropin). Coverage is limited to patients meeting age and diagnostic criteria for prepubertal cryptorchidism or hypogonadotropic hypogonadism; requests for fertility treatment or weight loss must be denied.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCibinqo (abrocitinib) Prior Authorization CriteriaThis policy governs prior authorization for Cibinqo (abrocitinib) for patients with refractory moderate-to-severe atopic dermatitis. It establishes initial and continuation requirements, safety screening, drug-combination restrictions, dosing expectations, and a six-month authorization period.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyColony-Stimulating FactorsThis policy governs prior authorization and coverage criteria for preferred and non-preferred colony-stimulating factor medications for cancer-related indications, severe chronic neutropenia, AIDS-related neutropenia, and chemotherapy- or radiation-induced neutropenia.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyConstipation Treatment AgentsThis policy governs prior authorization for selected prescription constipation treatment agents, including criteria for chronic idiopathic constipation, irritable bowel syndrome with constipation, and opioid-induced constipation. It applies to providers seeking coverage for eligible patients under the plan.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyCrenessity (crinecerfont) Prior Authorization CriteriaThis pharmacy policy governs prior authorization and continuation coverage for Crenessity (crinecerfont) in patients with classic congenital adrenal hyperplasia due to 21-hydroxylase deficiency. It applies to providers requesting coverage through the Agency for Health Care Administration.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyDalvance (dalbavancin) Prior Authorization CriteriaThis policy governs Medicaid fee-for-service prior authorization for Dalvance (dalbavancin) used to treat qualifying bacterial skin and skin structure infections. Coverage requires documentation of vancomycin failure or vancomycin resistance in the infecting gram-positive organism.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyDaybue and Daybue Stix (trofinetide) Coverage CriteriaThis policy governs prior authorization for trofinetide (Daybue and Daybue Stix) in patients with Rett syndrome. It establishes initial and continuation criteria, authorization durations, and dosing information for Medicaid fee-for-service providers.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyDiacomit (stiripentol) Coverage CriteriaPrior authorization coverage for Diacomit (stiripentol) in patients with Dravet syndrome, including clinical criteria, specialist involvement, adjunctive clobazam therapy, and hematologic monitoring.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyDupixent (dupilumab) Coverage and Prior AuthorizationThis policy governs prior authorization for Dupixent in Florida Medicaid fee-for-service and establishes initial and continuation coverage criteria for specified allergic, inflammatory, pulmonary, dermatologic, and gastrointestinal conditions.All Agency for Health Care Administration updates
- Coverage CriteriaClinical/Medical PolicyEPANED (enalapril) oral solution coverageThis policy governs prior authorization for EPANED (enalapril) oral solution under Florida Medicaid fee-for-service. It applies to patients requiring treatment for hypertension, symptomatic heart failure, or asymptomatic left ventricular dysfunction who meet the specified age, preferred-alternative trial, and continuation requirements.All Agency for Health Care Administration updates
1–25 of 79
1 / 4
Tool Description
Search Agency For Health Care Administration 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.