Aloha Care Coverage Criteria
Latest Aloha Care coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Antiemetics for Oncology (NK1 RA, 5HT3 RA, combination)Policy governing prior authorization, step therapy, and coverage criteria for antiemetic drugs used to prevent or treat chemotherapy-induced nausea and vomiting for Aloha Care members (Medicare and Medicaid specified in places). Affects providers requesting outpatient antiemetic drugs including injectable and oral NK1 RAs, 5HT3 RAs, and combination products.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-01-01Denosumab (Xgeva/Prolia and biosimilars) Medicare coverage criteriaMedicare (and Medicaid) prior authorization, quantity limits, preferred biosimilars, and clinical approval/renewal criteria for denosumab products (Xgeva/Prolia and listed biosimilars) provided under Aloha Care Medicare benefit.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-12-23Iron Preparations (Injectable/Intravenous Iron)Defines Aloha Care coverage, prior authorization, and clinical criteria for injectable iron products (e.g., Venofer, Ferrlecit, Injectafer, Feraheme, Monoferric, Triferic, Infed) for members, including Medicare Part B considerations and product-specific approval lengths.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-22Respiratory Interleukins — Coverage CriteriaDefines prior authorization, quantity/duration limits, step therapy, and medical benefit vs pharmacy benefit handling for specified respiratory interleukin biologic agents for Aloha Care members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-05White Blood Cell Growth Factors (G-CSF / GM-CSF) Coverage CriteriaDefines prior authorization, step therapy, preferred products, and clinical criteria for coverage of FDA‑approved colony stimulating factors (pegfilgrastim, filgrastim, eflapegrastim, efbemalenograstim, sargramostim) for Aloha Care members, including Medicare/Medicaid guidance.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-10-25Alpha-1 Proteinase InhibitorsDefines prior authorization, coverage criteria, and billing/coding guidance for alpha-1 proteinase inhibitor products (Aralast NP, Glassia, Prolastin-C, Zemaira) under Aloha Care; applies to Medicare/Medicaid lines of business and affected providers who request reimbursement.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-25Infliximab (medical benefit) — Medicare Part B coverage and prior authorization criteriaMedicare Part B coverage and prior authorization criteria for infliximab and its biosimilars for Aloha Care Medicare members, including indication-specific requirements and continuation/renewal conditions. Applies to medical benefit administration of infliximab products (J1745 and Q-codes).All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-10-20Durable Medical Equipment, Prosthetics & OrthoticsDefines AlohaCare's coverage, limitations, and medical necessity criteria for durable medical equipment (DME), prosthetics, and orthotics for members in applicable lines of business (Medicaid/MA, Quest Integration). Applies to items used in the home and ordered by a treating physician.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-20Rehabilitative Services PolicyDefines medical necessity, coverage criteria, limitations, prior authorization and billing guidance for outpatient physical therapy, occupational therapy, and speech therapy for Aloha Care members.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-10-20Rituximab and Biosimilars (Rituxan, Ruxience, Truxima, Riabni) — Medical Benefit Prior AuthorizationDefines Aloha Care medical benefit coverage, prior authorization, step therapy, and clinical criteria for rituximab and its biosimilars for Medicare and Medicaid populations.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-20pegaspargase (Oncaspar) — Medical Benefit Coverage CriteriaMedical benefit coverage criteria and authorization requirements for Oncaspar (pegaspargase) for AlohaCare Medicaid and Medicare members, including dosing, contraindications, and billing information.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-08-01Out-of-State Air Ambulance ServicesDefines clinical and administrative criteria for coverage of fixed-wing air ambulance transport from Hawaii to the continental United States for QUEST Integration (Medicaid) members; applies to inpatient and outpatient settings and affects providers seeking reimbursement for such transports.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-02Trastuzumab (Herceptin and biosimilars) Coverage CriteriaMedical policy governing coverage, prior authorization, step therapy, and clinical criteria for trastuzumab and its biosimilars for AlohaCare Medicaid & Medicare members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-20Perjeta (pertuzumab) — Medical Benefit Coverage CriteriaDefines medical-benefit coverage, authorization, and clinical criteria for pertuzumab (Perjeta) for AlohaCare Medicaid & Medicare members. Applies to Medical Benefit administration of Perjeta (HCPCS J9306).All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-01atezolizumab (Tecentriq) coverageMedical policy governing prior authorization, coverage criteria, and administration of atezolizumab (Tecentriq) for AlohaCare Medicaid and Medicare members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-01pembrolizumab (Keytruda) coverageDefines medical benefit coverage, prior authorization, step therapy, and clinical criteria for pembrolizumab (Keytruda) for AlohaCare Medicaid and Medicare members. Applies to requests for therapy supplied under the medical benefit (HCPCS J9271).All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2023-08-17efgartigimod (Vyvgart) — Medicare Part B coverage and prior authorization criteriaMedicare (Part B) coverage, prior authorization, and clinical criteria for efgartigimod products (Vyvgart IV and Vyvgart Hytrulo SC) for treatment of generalized myasthenia gravis in eligible members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-04-26Benign Skin Lesion RemovalDefines when removal or destruction of benign or premalignant skin lesions is considered medically necessary vs. cosmetic for AlohaCare members (includes QUEST Integration Medicaid and AlohaCare Advantage Plus SNP Medicare).All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-04-26Cell-Free Fetal DNA TestingDefines medical necessity, coverage criteria, coding guidance, and limitations for cffDNA/NIPT to screen for fetal trisomy (13, 18, 21) in pregnancy for Aloha Care members.All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2020-10-01Phesgo (pertuzumab-trastuzumab-hyaluronidase-zzxf) coverageThis policy defines medical benefit coverage, authorization, dosing, and Medicare Part B rules for Phesgo (pertuzumab-trastuzumab-hyaluronidase-zzxf) for AlohaCare Medicaid and Medicare members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-12-13Genetic Testing Colon Cancer Inherited RiskDefines medical necessity, coverage criteria, prior authorization, and limitations for genetic testing to evaluate inherited colorectal cancer syndromes for Aloha Care members (QUEST Integration Medicaid & Medicare).All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-12-13Genetic Testing Colon Cancer TreatmentCoverage policy for genetic and molecular tests used to guide treatment decisions in individuals with diagnosed colorectal cancer, applicable to AlohaCare QUEST Integration (Medicaid) and Medicare plans.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-09-06Genetic Counseling and Testing for Hereditary Breast and Ovarian Cancer Syndrome (HBOC)Defines medical necessity criteria, counseling requirements, limitations, and coding guidance for BRCA1/2 genetic testing and associated genetic counseling for members of Aloha Care plans (including QUEST Integration Medicaid and AlohaCare Advantage Plus SNP Medicare).All Aloha Care updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2019-04-06Hyaluronic Acids (Intra‑articular Knee Injections)This policy governs prior authorization, coverage criteria, quantity limits, and Medicare/Medicaid step therapy for hyaluronic acid (hyaluronan) intra‑articular knee injections for Aloha Care members.All Aloha Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-08-22Physical Therapy and Occupational Therapy Coverage CriteriaThis policy governs medical necessity, coverage criteria, prior authorization, documentation, limitations, and coding guidance for physical therapy (PT) and occupational therapy (OT) services for Aloha Care members.All Aloha Care updates
1–25 of 26
1 / 2
Tool Description
Search Aloha Care 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.