Amerihealth_caritas_vip_care Coverage Criteria
- Amerihealth_caritas_vip_care prior authorization
- Amerihealth_caritas_vip_care timely filing
- All Amerihealth_caritas_vip_care policy updates
Latest Amerihealth_caritas_vip_care coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-18Tezepelumab-ekko (Tezspire) Coverage CriteriaMedical-benefit coverage and medical necessity for tezepelumab-ekko in Medicare Advantage members with severe asthma or chronic rhinosinusitis with nasal polyposis, subject to Evidence of Coverage and clinical criteria.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01ElectroretinographyThis policy governs coverage of electroretinography used to localize and characterize retinocortical pathway dysfunction. It applies to providers requesting electroretinography for AmeriHealth Caritas VIP Care members, subject to medical-necessity criteria, plan benefits, and applicable laws and regulations.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15ADAMTS13, recombinant-krhn (Adzynma)This policy governs medical-necessity coverage and utilization requirements for ADAMTS13, recombinant-krhn (Adzynma) in adult and pediatric Medicare Advantage members with congenital thrombotic thrombocytopenic purpura (cTTP). It covers prophylactic therapy and on-demand treatment of acute TTP events when the stated diagnostic, specialist-prescribing, and dosing criteria are met.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Alemtuzumab (Lemtrada) Coverage for Relapsing Multiple SclerosisThis policy governs Part B medical-benefit coverage and medical necessity for intravenous alemtuzumab (Lemtrada) for Medicare Advantage members. Coverage is limited to specified relapsing multiple sclerosis indications, subject to benefit terms, documentation, and applicable authorization requirements.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Golimumab (Simponi Aria) Intravenous (IV) InjectionMedical-benefit coverage and medical necessity criteria for intravenous Simponi Aria (golimumab) for covered inflammatory arthritis indications in Medicare Advantage members; subcutaneous Simponi and Part D pharmacy-benefit coverage are outside this policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Lanreotide (Somatuline Depot)This policy governs medical-benefit coverage and medical necessity criteria for deep subcutaneous lanreotide injections for Medicare Advantage members. Coverage applies when the member's Evidence of Coverage permits the benefit and the policy's condition-specific criteria are met.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Ocrelizumab (Ocrevus) and Ocrelizumab and Hyaluronidase-ocsq (Ocrevus Zunovo)Part B medical-benefit coverage of intravenous Ocrevus and subcutaneous Ocrevus Zunovo for adults with specified forms of multiple sclerosis, subject to medical necessity criteria including negative hepatitis B testing; Part D pharmacy-benefit coverage is not addressed.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Spesolimab-sbzo (Spevigo) intravenous treatment for generalized pustular psoriasis flaresThis policy governs Medicare Advantage medical-benefit coverage and medical necessity for intravenous spesolimab-sbzo (Spevigo) in members with generalized pustular psoriasis flares, subject to benefit limitations and the criteria in this policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Teplizumab-mzwv (Tzield)This policy governs medical-benefit coverage and medical necessity for intravenous teplizumab-mzwv (Tzield) to delay the onset of stage 3 type 1 diabetes in adults and pediatric members aged 8 years and older with stage 2 type 1 diabetes. Coverage requires specified clinical criteria, documentation, dosing, and one treatment course per lifetime, subject to the member's benefit contract.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Teprotumumab (Tepezza) Coverage CriteriaMedicare Advantage coverage and reimbursement for intravenous teprotumumab-trbw (Tepezza) in adults with thyroid eye disease associated with confirmed Graves' disease, subject to medical necessity, clinical findings, prescribing, dosing, and frequency requirements.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-15Vedolizumab (Entyvio) for intravenous useThis policy governs medical-benefit coverage and prior authorization for intravenous vedolizumab in Medicare Advantage members. It applies to adults with specified inflammatory bowel disease, immune checkpoint inhibitor-related diarrhea or colitis, or steroid-refractory acute graft-versus-host disease when medical-necessity and dosing requirements are met.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-16Guselkumab (Tremfya) Injection for Intravenous UseThis policy governs medical-benefit coverage and medical necessity for intravenous guselkumab induction in adults with moderate-to-severe active ulcerative colitis or Crohn’s disease. It applies to Medicare Advantage members when Evidence of Coverage terms, clinical criteria, dosing requirements, and documentation requirements are met; subcutaneous and Part D coverage are generally outside this policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-28Alglucosidase alfa (e.g., Lumizyme®), Avalglucosidase alfa-ngpt (Nexviazyme®), Cipaglucosidase alfa-atga (Pombiliti™)Medical-benefit coverage and medical-necessity requirements for Lumizyme, Nexviazyme, and Pombiliti in eligible individuals with Pompe disease, subject to benefit terms, documented medical necessity, and specified dosing and frequency requirements.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-16Risankizumab-rzaa (Skyrizi) for Intravenous UseThis policy governs medical-benefit coverage and medical necessity requirements for intravenous risankizumab-rzaa (Skyrizi) in adults with moderately to severely active ulcerative colitis or Crohn's disease. It applies to Medicare Advantage members when applicable Evidence of Coverage terms, clinical criteria, and dosing requirements are met; pharmacy-benefit Part D coverage is not addressed.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-16Anifrolumab-fnia (Saphnelo) Coverage CriteriaMedical-benefit coverage of intravenous anifrolumab-fnia (Saphnelo) for adult Medicare Advantage members with moderate to severe systemic lupus erythematosus; pharmacy-benefit coverage is outside this policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-16Enteral Nutritional TherapyThis policy governs Medicare Advantage coverage of enteral nutrition, formulas, administration equipment, and supplies when oral nutrition is inadequate because of qualifying gastrointestinal or swallowing-related conditions. It also defines documentation, ordering, delivery, dispensing, reimbursement, and noncoverage requirements.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-05-07Rozanolixizumab-noli (Rystiggo) Coverage for Generalized Myasthenia GravisThis policy governs medical-benefit coverage and medical-necessity requirements for rozanolixizumab-noli (Rystiggo) in adults with generalized myasthenia gravis. Coverage is subject to the member’s Evidence of Coverage, benefit contract, applicable Medicare guidance, and the clinical criteria in this policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-05-07Triamcinolone Acetonide Extended-Release Injectable (Zilretta)This policy governs Medicare Advantage coverage and medical necessity requirements for intra-articular triamcinolone acetonide extended-release injectable (Zilretta) for adults with knee osteoarthritis. Coverage is subject to the member’s Evidence of Coverage and policy criteria; other uses, including repeat administration into the same knee, are generally experimental/investigational unless supported under the Company’s off-label coverage policy.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Pediatric Bed EnclosuresCoverage determinations for pediatric bed enclosures used at home to provide a safe sleeping environment for members at risk of falls, wandering, or self-harm, including applicable contraindications and noncovered equipment, accessories, and upgrades.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-10-24Belimumab (Benlysta®) for Intravenous UseThis policy governs Medicare Advantage Part B coverage and medical necessity for intravenous belimumab (Benlysta) in members with systemic lupus erythematosus or lupus nephritis. Coverage is subject to the applicable Evidence of Coverage, medical necessity criteria, and exclusions for experimental or investigational use.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-01Balloon dilation of the Eustachian tubeThis policy governs coverage of transnasal balloon dilation of the Eustachian tube, including selected adult and pediatric procedures and concurrent procedures. Coverage determinations are subject to the stated clinical criteria, plan benefits, and applicable laws and regulations.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-04-01Auricular Stimulation for Abdominal Pain From Irritable Bowel SyndromeCoverage determinations for percutaneous electrical nerve field stimulation, including IB-Stim, for functional abdominal pain related to irritable bowel syndrome; coverage may be medically necessary for members ages 4 through 18 who have not achieved adequate relief with gut-brain psychotherapies and other conservative measures.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-03-15Burosumab-twza (Crysvita) Coverage CriteriaMedical-benefit (Medicare Part B) coverage and medical necessity for burosumab-twza in eligible individuals with X-linked hypophosphatemia or tumor-induced osteomalacia, subject to applicable benefit limitations and clinical criteria.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-08-01Botulinum Toxin for ConstipationThis policy governs coverage of intrasphincteric botulinum toxin injection for refractory constipation and related defecatory disorders, identifying specific clinically proven indications and excluding other chronic defecatory disorders as investigational and not medically necessary.All amerihealth_caritas_vip_care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-02-01Latera Absorbable Nasal ImplantThis policy governs coverage of the Latera absorbable nasal implant for adults with symptomatic nasal airway obstruction caused by nasal valve collapse. Coverage is medically necessary only when specified clinical criteria are met; cosmetic and other uses are investigational or not medically necessary.All amerihealth_caritas_vip_care updates
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Tool Description
Search Amerihealth_caritas_vip_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.
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