Clover_health Coverage Criteria
Latest Clover_health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyAmondys 45 (casimersen) Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Amondys 45, including initial and continuation treatment of Duchenne muscular dystrophy. Coverage applies when the member meets the genetic, functional, age, dosing, and response criteria described in the policy.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyBiCNU (carmustine) Coverage CriteriaPrior authorization for BiCNU (carmustine) under Clover Health Medicare Part B for specified FDA-approved and compendial oncology indications when approval criteria are met and applicable exclusions do not apply.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyBizengri (zenocutuzumab-zbco) Part B CoverageMedicare Part B coverage and prior authorization for Bizengri in adults with specified advanced, unresectable, metastatic, or recurrent NRG1 gene fusion-positive NSCLC or pancreatic adenocarcinoma.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyBortezomib (Velcade) Coverage CriteriaMedicare Part B coverage and prior authorization for bortezomib (Velcade) for specified hematologic malignancies and related conditions, subject to approval criteria and applicable exclusions.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyBriumvi (ublituximab-xiiy) Coverage CriteriaThis policy governs Medicare Part B coverage and authorization for Briumvi (ublituximab-xiiy), including FDA-approved treatment of relapsing forms of multiple sclerosis and clinically isolated syndrome in adults. It applies to members requesting initial or continuation therapy when the stated coverage criteria are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyColumvi (glofitamab-gxbm) Coverage CriteriaThis policy governs Medicare Part B prior authorization and continuation coverage for Columvi, including FDA-approved and specified compendial uses in adult patients with relapsed or refractory B-cell lymphomas. Coverage requires satisfaction of the applicable clinical criteria and absence of exclusions to therapy.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyDatroway (datopotamab deruxtecan-dlnk) Part B Coverage and Prior AuthorizationThis policy governs Medicare Part B coverage and authorization for Datroway, including FDA-approved and compendial oncology uses in adults with specified breast cancer or non-small cell lung cancer. Coverage requires the applicable clinical criteria, documentation, and continuation-of-therapy requirements to be met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyDeferoxamine (Desferal) CoverageThis policy governs Medicare Part B coverage and authorization of deferoxamine mesylate (Desferal) for FDA-approved and compendial indications. Coverage applies when the applicable clinical criteria, documentation requirements, and continuation requirements are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyEnhertu and Trastuzumab Biologics Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Enhertu, trastuzumab, trastuzumab/hyaluronidase, and related trastuzumab biologics for breast, gastric, and gastroesophageal junction cancer in Florida, Puerto Rico, and the U.S. Virgin Islands.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyEylea, Eylea HD, and Aflibercept Biosimilars Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Eylea, Eylea HD, and specified aflibercept biosimilars for ophthalmic conditions when documented coverage criteria are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyIntramuscular Immune Globulin Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for intramuscular immune globulin, including GamaSTAN, for specified infectious-disease exposures and immunoglobulin deficiency. Coverage applies in the listed jurisdiction states when approval criteria are met and the member has no exclusions to the prescribed therapy.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyIxempra (ixabepilone) Coverage CriteriaThis policy governs prior authorization for Ixempra in patients with breast cancer, including initiation and continuation requirements, disease characteristics, prior therapy, combination use, HER2 testing, treatment benefit, and hepatic laboratory parameters.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJevtana (cabazitaxel) Coverage CriteriaThis policy governs Clover Health prior authorization criteria for Jevtana (cabazitaxel) in patients with metastatic castration-resistant prostate cancer. It applies to providers requesting initiation or continuation of therapy.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B AranespThis policy governs prior authorization and medical-necessity requirements for Aranesp (darbepoetin alfa) administered under Medicare Part B for qualifying chemotherapy-related, ESRD or CKD-related, and selected lower-risk MDS anemias.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B Bisphosphonate Drug TherapyThis policy governs coverage and prior authorization for intravenous ibandronate sodium, pamidronate disodium, and zoledronic acid under Medicare Part B. It applies to Clover Health members in the specified Medicare jurisdictions when treatment is requested for listed covered indications and the applicable clinical criteria are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B DysportClover Health Medicare Part B coverage and prior authorization for Dysport (abobotulinumtoxinA), including covered indications, clinical criteria, exclusions, and treatment frequency in Kentucky and Ohio.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B GranixThis policy governs prior authorization and coverage of Granix under Medicare Part B for specified neutropenia-related uses in Medicare jurisdictions J and M, including clinical criteria, exclusions, authorization durations, and administration requirements.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B HyaluronansThis policy governs coverage and authorization of specified hyaluronan products administered under Medicare Part B for osteoarthritis, shoulder impingement syndrome, and other approved indications. It applies to members in the specified Medicare Administrative Contractor jurisdictions when the stated clinical criteria and applicable exclusions are satisfied.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B Intravenous Immune Globulin (IVIG)This policy governs coverage and prior authorization for brand and generic IVIG products administered under Medicare Part B in Jurisdiction 6 and Jurisdiction K states when an approved indication and applicable clinical criteria are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B MirceraThis policy governs Medicare Part B coverage and prior authorization for Mircera in members with specified anemia related to ESRD or CKD, including certain pediatric members converting from another ESA, in Medicare Part B Jurisdictions J and M.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B Octreotide Acetate for Injectable Suspension (Sandostatin LAR)Prior authorization and Medicare Part B coverage of octreotide acetate injectable suspension for specified FDA-labeled and compendial indications in Medicare Administrative Contractor Jurisdictions J and M, including AL, GA, TN, NC, SC, VA, and WV.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B Prolia and BiosimilarsPrior authorization and coverage criteria for Prolia and listed denosumab biosimilars administered under Medicare Part B in Clover Health jurisdictions 6 and K.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyJurisdiction Specific Medicare Part B SusvimoPrior authorization coverage for Susvimo (ranibizumab), including brand and generic products and all dosage forms and strengths, for Medicare Part B members in specified Medicare Administrative Contractor jurisdictions when applicable clinical criteria are met.All clover_health updates
- Coverage CriteriaClinical/Medical PolicyRybrevant Faspro (amivantamab and hyaluronidase-lpuj) Coverage CriteriaMedicare Part B prior authorization and coverage for Rybrevant Faspro in adults with advanced, recurrent, or metastatic NSCLC, including specified EGFR mutation-positive disease and combination regimens.All clover_health updates
- Coverage CriteriaClinical/Medical PolicySandostatin LAR Depot (octreotide acetate) Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Sandostatin LAR Depot, including FDA-approved and compendial indications, when approval criteria are met and no exclusions apply.All clover_health updates
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Tool Description
Search Clover_health 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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