Careoregon Coverage Criteria
Latest Careoregon coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-26Pharmacy & Specialty Drugs — Coverage Criteria (Abilify Mycite and listed specialty drug prior authorization criteria)This policy lists prior authorization criteria and coverage requirements for Abilify Mycite (Maintenance and Starter Kits) and multiple specialty pharmacy products; it specifies required documentation, prerequisite therapy, prescriber restrictions, initial and renewal coverage durations, and exclusions for CareOregon members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-22Prior authorization guideline — Liraglutide (generic)Prior authorization guideline for liraglutide (generic) covering multiple indications including type 2 diabetes, chronic kidney disease, and diabetes with obstructive sleep apnea for CareOregon Medicaid members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Adempas (riociguat) prior authorizationThis policy governs prior authorization requirements for Adempas (riociguat) for members of CareOregon; it specifies approval length and clinical criteria for use in pulmonary arterial hypertension (WHO Group 1).All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Allergy immunotherapy (sublingual allergen extracts) coverage criteriaPrior authorization guideline for specific FDA‑approved allergen immunotherapy products (Grastek, Odactra, Oralair, Ragwitek) governing initial authorization and reauthorization criteria for CareOregon members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Andembry (garadacimab) — Prior Authorization GuidelinePrior authorization guideline for Andembry (garadacimab) for treatment of hereditary angioedema (HAE), covering initial and reauthorization clinical criteria and approval length. Applies to CareOregon-managed members requiring this specialty drug.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Dapagliflozin-containing products prior authorizationThis document governs prior authorization requirements for dapagliflozin and combination dapagliflozin/metformin products for CareOregon members, specifying clinical criteria and documentation required for approval.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Desmopressin prior authorizationDefines prior authorization requirements for desmopressin products (nasal spray and nasal solution) for members of CareOregon; governs coverage criteria and approval lengths for specified diagnoses.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Dipeptidyl peptidase 4 (DPP-4) inhibitors prior authorizationThis guideline governs prior authorization for DPP-4 inhibitor products (alogliptin and combination products) for CareOregon members, specifying approval length and clinical step criteria for coverage.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Erythropoetin Stimulating Agents prior authorizationPrior authorization guideline for erythropoietin stimulating agents (e.g., Aranesp, Retacrit) describing initial and reauthorization clinical criteria, approval durations, and required laboratory parameters for members receiving CareOregon coverage.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Growth Hormone Prior AuthorizationDefines prior authorization requirements for branded growth hormone products for adult and pediatric members, including clinical criteria, prescriber requirements, product-step rationale, required documentation, and a 12-month approval length.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Lisdexamfetamine (generic lisdexamfetamine capsule) prior authorizationThis document governs prior authorization requirements for generic lisdexamfetamine capsules (approval length: lifetime) for members covered by CareOregon; it specifies clinical criteria for ADHD and binge eating disorder and who may prescribe for BED.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Mesalamine prior authorization guidelinePrior authorization guideline for mesalamine products (generic mesalamine and Pentasa) for Crohn's disease and ulcerative colitis; defines coverage criteria, step therapy, documentation, and approval length.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Multiple sclerosis disease-modifying agents (fingolimod, Mayzent)Prior authorization guideline for coverage of fingolimod (generic) and Mayzent (siponimod) for members with multiple sclerosis; specifies clinical criteria, prescriber requirements, and approval durations for CareOregon members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Myeloid Growth Factors (G-CSFs) — Prior Authorization GuidelinePrior authorization guideline for myeloid growth factors (e.g., Fylnetra, Nivestym) governing medical necessity criteria and approval length for CareOregon members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Onureg (azacitidine - oral) prior authorizationDefines prior authorization requirements and coverage criteria for Onureg (oral azacitidine) for CareOregon members, including initial and reauthorization criteria and required prescriber specialty. Affects providers requesting coverage for Onureg.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01PCSK9 Inhibitors (Repatha, Praluent) Prior Authorization GuidelinePrior authorization guideline for use of PCSK9 inhibitors (Repatha and Praluent) describing initial and reauthorization clinical criteria, prescriber requirements, and approval durations; applies to CareOregon members for formulary management.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Paricalcitol prior authorizationThis document is a CareOregon prior authorization guideline that defines criteria for coverage of generic paricalcitol for members with chronic kidney disease; it applies to providers requesting prior authorization from this payer.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Prior authorization guideline — Testosterone topical gels and pumpsPrior authorization guideline for generic testosterone topical products (1.62% gel and 1% gel/pump) describing coverage criteria for diagnoses including AIDS wasting syndrome, metastatic breast cancer palliation, gender dysphoria, and hypogonadism. Applies to CareOregon members requesting covered testosterone topical formulations.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Prior authorization: Generic Candesartan / Candesartan HCTPrior authorization guideline for coverage of generic candesartan and candesartan/hydrochlorothiazide products, specifying clinical criteria and documentation required for approval. Affects providers requesting coverage from CareOregon for these medications.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Soliqua (insulin glargine/lixisenatide) prior authorizationPrior authorization requirements for coverage of Soliqua (insulin glargine/lixisenatide) for members, including initial authorization and reauthorization clinical criteria and documentation expectations.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Takhzyro (lanadelumab-flyo) prior authorizationPrior authorization requirements for initiation and reauthorization of Takhzyro (lanadelumab-flyo) for treatment of hereditary angioedema (HAE) for CareOregon members.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Trelegy Ellipta (fluticasone-umeclidinium-vilanterol) prior authorizationPrior authorization requirements for Trelegy Ellipta (fluticasone-umeclidinium-vilanterol) covering approval length and clinical criteria for members requiring this inhaled combination therapy.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Vijoice (alpelisib) prior authorization for PIK3CA-Related Overgrowth Spectrum (PROS)This prior authorization guideline establishes coverage criteria, required documentation, and approval lengths for Vijoice (alpelisib) for members with PIK3CA-Related Overgrowth Spectrum (PROS) and applies to CareOregon prior authorization reviewers and prescribing clinicians.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Vyndamax (tafamidis) prior authorization for ATTR-CMPrior authorization criteria for coverage of Vyndamax (tafamidis) for treatment of transthyretin-mediated amyloidosis with cardiomyopathy (ATTR-CM); applies to prescribers seeking approval for initiation or continuation of therapy under the payer's guideline.All careoregon updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Wayrilz (rilzabrutinib) prior authorization for immune thrombocytopenic purpura (ITP)Prior authorization requirements for initiation and reauthorization of Wayrilz (rilzabrutinib) for members with immune thrombocytopenic purpura (ITP), including clinical criteria and documentation required for CareOregon members.All careoregon updates
1–25 of 97
1 / 4
Tool Description
Search Careoregon 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.