AvMed Coverage Criteria
Latest AvMed coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-26Prior authorization and coverage criteria for Vyleesi (bremelanotide)This document is a prior authorization/step-edit request form and clinical criteria for coverage of Vyleesi (bremelanotide) for members of AvMed. It governs prescriber submission requirements and clinical eligibility for Vyleesi therapy.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Abecma (idecabtagene vicleucel) IV prior authorizationPrior authorization form and medical necessity criteria for Abecma (idecabtagene vicleucel) IV (HCPCS Q2055) for treatment of relapsed or refractory multiple myeloma, including provider, patient, dosing, quantity limits, and required clinical documentation.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Abrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage CriteriaDefines prior authorization and clinical criteria for covering Abrysvo (RSV vaccine) during pregnancy for AvMed members; applies to providers requesting medical (office-administered) coverage. Affects pregnant members and prescribers submitting PA requests.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Actimmune (interferon gamma-1b) prior authorizationThis document governs prior authorization and step-edit requests for Actimmune (interferon gamma-1b) for AvMed members, specifying required prescriber signatures, clinical criteria for Chronic Granulomatous Disease and severe malignant osteopetrosis, and documentation needed for approval.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Adakveo (crizanlizumab-tmca) prior authorizationRequirements and clinical criteria for AvMed medical prior authorization of Adakveo (crizanlizumab-tmca) for reducing vaso-occlusive crises in patients with sickle cell disease; applies to providers requesting coverage for the medication.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Adstiladrin (nadofaragene firadenovec-vncg) prior authorization — Non‑muscle invasive bladder cancerRequirements and clinical criteria for prior authorization of Adstiladrin (J9029) for treatment of non‑muscle invasive bladder cancer in AvMed members; intended for prescribing providers and facility staff submitting PA/step-edit requests.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Adzynma (ADAMTS13 recombinant-krhn) — Prior Authorization for congenital TTP (cTTP)Prior authorization and clinical criteria for medical (clinic/infusion) use of Adzynma for congenital thrombotic thrombocytopenic purpura (cTTP) for AvMed members; applies to providers requesting coverage of prophylactic or on-demand therapy.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Aflibercept (Eylea) for Retinopathy of Prematurity — Prior Authorization Coverage CriteriaPrior authorization form and clinical criteria for coverage of Eylea (aflibercept J0177) for treatment of Retinopathy of Prematurity (ROP) in premature infants; intended for AvMed providers requesting outpatient drug approval.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Aldurazyme (laronidase) prior authorization for MPS IRequirements and clinical criteria for prior authorization and continuation of intravenous Aldurazyme (laronidase) for members with mucopolysaccharidosis type I (MPS I); applies to providers requesting medical benefit coverage from AvMed.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Alpha Proteinase Inhibitors (Medical)Prior authorization policy for intravenous alpha-1 antitrypsin (AAT) augmentation therapy (Aralast NP, Glassia, Prolastin-C, Zemaira) including initial and continuation authorization clinical criteria, quantity limits (NDCs/HCPCS units), and administrative submission requirements for AvMed members.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Amtagvi (lifileucel) medical prior authorizationPrior authorization form and medical coverage criteria for Amtagvi (lifileucel) administered under the medical benefit (J9999). Defines patient eligibility, clinical exclusion criteria, dosing limits, provider and site requirements, and documentation/submission instructions for approval of a single lifetime treatment course.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Aucatzyl (obecabtagene autoleucel) — Medical Prior Authorization / Coverage CriteriaThis document governs prior authorization and step-edit requests for Aucatzyl (obecabtagene autoleucel) for AvMed members, specifying required documentation, clinical eligibility, dosing, and site-of-care information for providers requesting coverage.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Azedra (iobenguane I-131) IV — Prior Authorization and Medical Necessity CriteriaPrior authorization form and medical necessity criteria for AvMed coverage of Azedra (iobenguane I-131) IV for treatment of pheochromocytoma and paraganglioma, affecting providers prescribing or administering the drug for AvMed members in North Carolina.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Benlysta (belimumab) intravenous infusion prior authorizationPrior authorization and step-edit request form and clinical criteria for medical (J0490) use of Benlysta (belimumab) for treatment of systemic lupus erythematosus and lupus nephritis; applies to providers submitting requests to AvMed.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Beqvez (fidanacogene elaparvovec‑dzkt) prior authorization for Hemophilia BForm and clinical criteria governing prior authorization for use of Beqvez (fidanacogene elaparvovec-dzkt) for members with moderate to severe congenital factor IX deficiency (Hemophilia B); applies to AvMed providers requesting medical (J3590) coverage. Affects prescribers, administering sites, and specialty pharmacy workflows.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Botox (onabotulinumtoxinA, J0585) — Prior Authorization and Clinical Criteria for Upper and Lower Limb SpasticityPrior authorization and step-edit request form and clinical criteria for coverage of Botox (onabotulinumtoxinA, J0585) for treatment of upper limb spasticity (ULS) and lower limb spasticity (LLS) for AvMed members; applies to prescribing providers requesting authorization.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Botulinum toxin Type A (onabotulinumtoxinA) for primary axillary hyperhidrosis — Prior authorization / step-edit criteriaThis prior authorization/step-edit form governs medical approval requirements for Botox (onabotulinumtoxinA, J0585) used to treat primary axillary hyperhidrosis for AvMed members; it specifies documentation, clinical criteria, dosing limits, and prior therapy requirements that prescribers must meet.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Botulinum toxin type A injections (Botox, Xeomin) prior authorizationThis form and policy govern prior authorization and step-edit requests for medical use of botulinum toxin type A (onabotulinumtoxinA, incobotulinumtoxinA) for AvMed members, specifying clinical criteria, documentation, limits, and submission instructions for providers.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Breyanzi (lisocabtagene maraleucel) medical prior authorization — coverage criteriaPrior authorization form and clinical criteria for medical benefit coverage of Breyanzi (lisocabtagene maraleucel) for adult members with specified B-cell malignancies; applies to providers requesting AvMed coverage in North Carolina.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Brineura IV (Medical)Prior authorization form and medical policy criteria for Brineura (cerliponase alfa) administered intraventricularly (ICV) for symptomatic late infantile neuronal ceroid lipofuscinosis type 2 (CLN2). Defines initial and reauthorization clinical criteria, dosing recommendation, administration site options, and duration of approvals.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Briumvi (ublituximab) prior authorizationRequirements and clinical criteria for AvMed medical prior authorization and step-edit requests for Briumvi (ublituximab) for treatment of relapsing forms of multiple sclerosis; applies to providers submitting requests for AvMed members.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Cabenuva (cabotegravir/rilpivirine) prior authorization and coverage criteriaThis document governs prior authorization and step-edit requirements for Cabenuva (cabotegravir/rilpivirine) long-acting injectable therapy for AvMed members, describing required provider actions, clinical criteria, and quantity limits.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Canakinumab (Ilaris) prior authorization for sJIA and AOSDThis form and policy govern prior authorization and step-edit requirements for providing canakinumab (Ilaris) for members with systemic juvenile idiopathic arthritis (sJIA) or adult onset Still's disease (AOSD) through AvMed. It affects prescribers seeking medical benefit coverage for Ilaris and specifies clinical criteria, documentation, and review periods.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Carvykti (ciltacabtagene autoleucel) — Medical Prior Authorization (Part B)This form governs prior authorization and step-edit requests for Carvykti (ciltacabtagene autoleucel) as a medical (Part B) infusion product for AvMed members and specifies clinical criteria, documentation, and administrative requirements for providers.All AvMed updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-11-12Casgevy - β - Thalassemia (Medical)Medical prior authorization form and clinical coverage criteria for one lifetime treatment of Casgevy (exagamglogene autotemcel) for members with β-thalassemia. Defines clinical eligibility requirements, dosing limits, required documentation, provider qualifications, and administration site options.All AvMed updates
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Tool Description
Search AvMed 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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