Allcareadvantage Coverage Criteria
Latest Allcareadvantage coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Approval criteria for Non-preferred inhalers and/or regimensDefines prior authorization and approval criteria for coverage of non-preferred inhaler products and inhaler regimens for members with asthma, reactive airways disease (RAD), or COPD who are established on a reliever (e.g., albuterol). Applies to AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-25Topical Janus Kinase InhibitorsDefines prior authorization and coverage criteria for topical JAK inhibitor therapies (delgocitinib, ruxolitinib) for treatment of chronic hand eczema in adult AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-31Anti-VEGF antibodies (intravitreal) prior authorizationDefines prior authorization, coverage criteria, and renewal requirements for intravitreal anti-VEGF antibody agents for retinal diseases for AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-19Ensifentrine (Ohtuvayre) — Coverage Criteria for Maintenance Treatment of COPDPrior authorization and coverage criteria for ensifentrine (Ohtuvayre) as maintenance treatment for adult patients with COPD under AllCare Advantage.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-06-26Linezolid (Zyvox) prior authorizationDefines prior authorization requirements and coverage criteria for the antibiotic linezolid (Zyvox) for AllCare Advantage members, including indications, documentation, and renewal rules for treatment of MRSA and VRE infections.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-14Prior authorization criteria for vonoprazan (Potassium-competitive acid blocker)Defines prior authorization criteria for coverage of the potassium-competitive acid blocker vonoprazan (Voquezna) for AllCare Advantage / AllCare CCO members, including indications for erosive esophagitis and H. pylori treatment, and renewal conditions.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-14Prior authorization criteria for anifrolumab (Saphnelo) for systemic lupus erythematosusPrior authorization criteria for coverage of anifrolumab (Saphnelo) for adults with moderate to severe systemic lupus erythematosus when used with standard therapy; applies to AllCare Advantage / AllCare CCO members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-01Demodex blepharitis agents (lotilaner/Xdemvy) - Prior Authorization CriteriaDefines prior authorization and coverage criteria for lotilaner ophthalmic solution (Xdemvy) for treatment of Demodex blepharitis for AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-21Kinase inhibitors for alopeciaDefines prior authorization and coverage criteria for kinase inhibitor medications (baricitinib/Olumiant and ritlecitinib/Litfulo) used to treat severe alopecia areata for AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-22Calcitonin gene-related peptide (CGRP) receptor agentsDefines prior authorization criteria for coverage of formulary calcitonin gene-related peptide (CGRP) receptor agents for prevention and acute treatment of migraine for AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-07Pediatric obesity — Pharmacotherapy prior authorizationGoverns prior authorization and coverage criteria for formulary FDA‑approved medications for pediatric weight loss for AllCare Advantage members up to age 20, including approval and renewal requirements.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-02Anti‑Alzheimer Agents prior authorizationDefines prior authorization, coverage criteria, and renewal requirements for anti‑Alzheimer agents (FDA‑approved treatment of Alzheimer's disease) for AllCare Advantage members aged ≥18. Applies to coverage determinations and documentation required for approval and renewal.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-08-09sacubitril-valsartan (Entresto) prior authorizationDefines coverage and prior authorization criteria for sacubitril-valsartan (Entresto) for adults with chronic heart failure with reduced ejection fraction (NYHA II-IV), including approval length, dosing expectations, and quantity limits.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-06-14Approval Criteria for Leukotriene inhibitorsPrior authorization and coverage criteria for leukotriene inhibitor medications for members, primarily for asthma indications; defines required trials, age limits, coverage status, and approval length.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-06-14Approval Criteria for Mepolizumab (Anti-IL5) — Coverage & Prior AuthorizationDefines AllCare Advantage coverage, prior authorization, approval lengths, quantity limits, and clinical criteria for mepolizumab (and benralizumab) for severe eosinophilic asthma and mepolizumab for eosinophilic granulomatosis with polyangiitis (EGPA). Affects providers requesting PA for these agents.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-06-14Ipratropium (Atrovent) prior authorization and coverage criteriaDefines prior authorization and coverage criteria for ipratropium (Atrovent) inhalers and nebulizer solution for AllCare Advantage members, including COPD and certain off-label asthma uses. Applies to prescription drug benefit managed by the payer.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-05-23Drug Specific: levoketoconazole (Recorlev) - Prior Authorization CriteriaDefines prior authorization, initial and renewal coverage criteria, and quantity/approval limits for levoketoconazole (Recorlev) for treatment of Cushing's syndrome in eligible members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-04-15Opioids for Neuropathic PainDefines prior authorization and coverage criteria for formulary opioids used to treat neuropathic pain for AllCare Advantage members, including limits and required trials of non-opioid therapies.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-03-17Class Specific: myasthenia gravis agents (prior authorization and coverage criteria)Prior authorization and coverage criteria for specified myasthenia gravis agents for adults, including initial and renewal approval rules and required clinical documentation.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-06-01Belimumab (Benlysta) prior authorization — coverage criteria for SLE and lupus nephritisDefines prior authorization criteria, approval length, quantity limits, and clinical requirements for coverage of belimumab (Benlysta) for members with systemic lupus erythematosus (SLE) or lupus nephritis (LN). Applies to AllCare Advantage prior authorization review for prescribers and reviewers.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-06-01voclosporin (Lupkynis) — calcineurin‑inhibitor immunosuppressant coverage criteriaDefines prior authorization and renewal criteria for coverage of the calcineurin‑inhibitor voclosporin (Lupkynis) for adult patients with active lupus nephritis; applies to AllCare Advantage members requiring PA for this agent.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-10-22Approval Criteria for Non-Formulary Buprenorphine (Butrans)Defines prior authorization and approval criteria for coverage of transdermal buprenorphine patches (Butrans) for AllCare Advantage members with chronic pain who cannot take oral opioids or use fentanyl patches. Applies to requests for non-formulary Butrans; oral buprenorphine for MAT is handled separately.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-10-22Fenfluramine (Fintepla) for seizures associated with Dravet syndrome — Coverage CriteriaPrior authorization and coverage criteria for fenfluramine (Fintepla) to treat seizures associated with Dravet syndrome for members aged 2 years and older; applies to prescribers and prior authorization reviewers for AllCare Advantage members.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-03-12dalfampridine (Ampyra) prior authorizationDefines AllCare Advantage prior authorization, coverage criteria, and renewal requirements for dalfampridine (Ampyra) for adults with multiple sclerosis who have walking impairment.All allcareadvantage updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-08-15Onasemnogene abeparvovec-xioi (Zolgensma) coverageDefines prior authorization, coverage criteria, and limits for onasemnogene abeparvovec-xioi (Zolgensma) for AllCare members with spinal muscular atrophy (SMA), focusing on pediatric patients under 2 years of age.All allcareadvantage updates
1–25 of 60
1 / 3
Tool Description
Search Allcareadvantage 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.