Caresourcegeorgia Coverage Criteria
Latest Caresourcegeorgia coverage criteria updates9
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Syfovre (pegcetacoplan) for geographic atrophy secondary to age-related macular degenerationThis policy governs medical prior authorization coverage of intravitreal Syfovre for geographic atrophy secondary to age-related macular degeneration in CareSource Georgia Medicaid members. It establishes initial authorization, reauthorization, dosing, quantity limits, and conditions considered not medically necessary.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Spravato (esketamine) Coverage CriteriaThis policy governs prior authorization and coverage of Spravato (esketamine) for adults with major depressive disorder with acute suicidal ideation or behavior, or treatment-resistant major depressive disorder. It applies to CareSource Georgia Medicaid pharmacy or medical benefit billing.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Tecartus (brexucabtagene autoleucel) Coverage CriteriaCareSource Georgia Medicaid coverage and medical prior authorization for Tecartus in adults with specified relapsed or refractory mantle cell lymphoma or B-cell acute lymphoblastic leukemia.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Vijoice (alpelisib) for PIK3CA-Related Overgrowth SpectrumPharmacy prior authorization and coverage criteria for Vijoice (alpelisib) for CareSource Georgia Medicaid members age 2 years and older with severe manifestations of PIK3CA-Related Overgrowth Spectrum (PROS).All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Kineret (anakinra) Coverage CriteriaGeorgia Medicaid pharmacy prior authorization for Kineret (anakinra), including initial and renewal coverage for rheumatoid arthritis, CAPS/NOMID, and DIRA.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Xolair (omalizumab) Coverage CriteriaThis policy governs CareSource Georgia Medicaid coverage and prior authorization for Xolair (omalizumab) used for chronic rhinosinusitis with nasal polyps, chronic spontaneous urticaria, moderate-to-severe persistent asthma, and IgE-mediated food allergy. It establishes indication-specific clinical criteria, dosing limits, documentation requirements, initial authorization periods, and reauthorization requirements.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Zoladex (goserelin acetate) Medical Prior AuthorizationCareSource Georgia Medicaid coverage of Zoladex for premenopausal adults with dysfunctional uterine bleeding undergoing endometrial ablation or symptomatic, confirmed endometriosis; specified clinical criteria, documentation, and quantity limits apply, and reauthorization is not permitted.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Xalkori (crizotinib) Coverage Criteria for Inflammatory Myofibroblastic TumorGeorgia Medicaid pharmacy prior authorization coverage for Xalkori (crizotinib), primarily for members age 1 year and older with unresectable, recurrent, or refractory ALK-positive inflammatory myofibroblastic tumor; includes authorization criteria, reauthorization, dosage and quantity limits, and cancer request routing.All caresourcegeorgia updates
- Coverage CriteriaClinical/Medical PolicyProlia (denosumab) Coverage CriteriaGeorgia Medicaid medical prior authorization and renewal requirements for Prolia (denosumab) used for osteoporosis, glucocorticoid-induced osteoporosis, and cancer-treatment-related bone loss.All caresourcegeorgia updates
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Tool Description
Search Caresourcegeorgia 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
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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.
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