Community-Care Coverage Criteria
Latest Community-Care coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Lumizyme (alglucosidase alfa) — Medical Benefit Medication Utilization PolicyDefines medical benefit coverage criteria, authorization, quantity limits, and coding for Lumizyme (alglucosidase alfa) for treatment of Pompe disease for Community-Care members.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-01SylvantThis policy defines coverage criteria, laboratory thresholds, dosing rounding, continuation criteria, quantity limits, authorization period, and applicable billing code for siltuximab (Sylvant) when used to treat multicentric Castleman disease (MCD)/iMCD.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-06-01Medical Benefit Medication Utilization Policy — sebelipase alfa (LAL deficiency) coverage criteriaThis policy defines medical benefit coverage criteria, authorization, quantity limits, and coding for sebelipase alfa for treatment of lysosomal acid lipase (LAL) deficiency for members under the payer's medical benefit.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyAdenosine deaminase severe combined immune deficiency (ADA-SCID) medication therapy coverage criteriaDefines medical benefit coverage criteria, authorization periods, quantity limits, and required documentation for initial and continued therapy for ADA-SCID; applies to providers and members under Community-Care policies.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyAdzynmaDefines medical-benefit coverage criteria for initial and continued use of rADAMTS13 (Adzynma) to treat congenital thrombotic thrombocytopenic purpura (cTTP), quantity limits, authorization period, and applicable billing code(s).All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyAlpha1‑antitrypsin (AAT) augmentation therapy — Medical Benefit Medication Utilization PolicyMedical benefit coverage policy for alpha1 proteinase inhibitor products (Aralast‑NP, Glassia, Prolastin‑C, Zemaira) for members with congenital alpha1‑antitrypsin deficiency, governing initial approval, quantity limits, and coding for Community‑Care.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyAmvuttra (vutrisiran) medical benefit coverageDefines medical necessity criteria, quantity limits, and authorization requirements for Amvuttra (vutrisiran) for treatment of hATTR polyneuropathy and ATTR cardiomyopathy for affected members and prescribers.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyAvacincaptad pegol (J2782) — medical benefit coverage criteria for geographic atrophy (age-related macular degeneration)Defines medical benefit coverage criteria, quantity limits, and authorization period for avacincaptad pegol to treat geographic atrophy secondary to age-related macular degeneration for members under the payer's medical benefit.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBenlysta IV (belimumab) Medical Benefit Medication Utilization PolicyDefines medical benefit coverage criteria, authorization, and coding for intravenous belimumab (Benlysta) for systemic lupus erythematosus and active lupus nephritis for Community-Care members and providers.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBeovu (brolucizumab) — Medical Benefit Medication Utilization PolicyDefines clinical coverage criteria, quantity limits, authorization period, and billing codes for Beovu (brolucizumab) when billed under the medical benefit for neovascular (wet) AMD and diabetic macular edema.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBeremagene geperpavec (topical) for dystrophic epidermolysis bullosa — Medical Benefit Coverage CriteriaDefines medical benefit coverage, authorization, and quantity limits for beremagene geperpavec used to treat dystrophic epidermolysis bullosa (DEB) for members covered under the payer's medical benefit.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBotulinum toxin products — medical coverage criteriaDefines coverage, prior authorization, quantity limits, and continuation criteria for botulinum toxin products (preferred: Botox, Dysport, Xeomin) across neurologic and related indications for Community-Care members in North Carolina.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBrineura (cerliponase alfa) — Medical Benefit Coverage CriteriaDefines clinical and administrative criteria for initial and continued medical-benefit coverage of Brineura (cerliponase alfa) for treatment of CLN2/TPP1 deficiency for Community-Care members.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyBurosumab (Crysvita) medical benefit coverage — X-linked hypophosphatemia and tumor-induced osteomalaciaDefines medical necessity criteria, authorization periods, quantity limits, and coding for burosumab (Crysvita) for X-linked hypophosphatemia and tumor-induced osteomalacia for Community-Care members and providers.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCerezyme (imiglucerase) — Medical Benefit Coverage Criteria for Gaucher Disease Type 1Defines medical benefit coverage criteria, authorization, and coding for Cerezyme (imiglucerase) for members with Gaucher disease type 1; applies to prescribers and payers managing medication benefits.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCinqair (reslizumab) Medical Benefit Medication Utilization PolicyDefines medical-coverage criteria, quantity limits, authorization periods, and applicable billing codes for reslizumab (Cinqair) when used to treat eosinophilic severe asthma in adults under the medical benefit.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCipaglucosidase alfa (Pombiliti) for late-onset Pompe disease — Coverage CriteriaDefines medical benefit coverage criteria for initiation and continuation of cipaglucosidase alfa (Pombiliti) for members with late-onset Pompe disease, and applies to providers seeking authorization under the payer's medical benefit medication policy.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCollagenase (Clostridium histolyticum) injections — Coverage Criteria for Dupuytren's contracture and Peyronie's diseaseClinical coverage criteria and authorization rules for injection of collagenase (clostridium histolyticum) for Dupuytren's contracture and Peyronie's disease for Community-Care members.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCommunityCare ACA Prescription Drug Formulary (partial) - Coverage CriteriaDescribes CommunityCare ACA prescription drug list structure, member obligations to use network pharmacies, formulary rules (prior authorization, step therapy, quantity limits), tiers and copay structure, and examples affecting CommunityCare ACA members and their prescribing providers/pharmacies.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyCoverage criteria for pegunigalsidase alfa (Elfabrio) for Fabry diseaseCriteria for medical benefit coverage and authorization of pegunigalsidase alfa (Elfabrio) for treatment of Fabry disease for affected members and prescribing providers.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyDDAVP (desmopressin) Medical Benefit Medication Utilization PolicyDefines coverage criteria for initial and continuation approval of desmopressin (DDAVP) for diabetes insipidus, Hemophilia A, and von Willebrand Disease; includes quantity limits, authorization period, and applicable HCPCS code(s).All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyDelandistrogene moxeparvovec (Elevidys) — Coverage Criteria for Duchenne muscular dystrophyThis medical benefit medication utilization policy defines coverage criteria, quantity limits, and authorization period for delandistrogene moxeparvovec (Elevidys) for members with Duchenne muscular dystrophy (DMD). It applies to providers seeking prior authorization for this therapy.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyDifelikefalin (for CKD-associated pruritus) — Coverage CriteriaMedical benefit policy governing coverage criteria for difelikefalin to treat moderate-to-severe pruritus in patients with end-stage kidney disease on hemodialysis; affects prescribers, dialysis providers, and payers.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyDurysta (bimatoprost intracameral implant) — Coverage CriteriaMedical benefit medication utilization policy governing coverage and authorization criteria for Durysta (bimatoprost intracameral implant) for treating elevated intraocular pressure in adults; applies to providers and members under the payer's jurisdiction.All Community-Care updates
- Coverage CriteriaClinical/Medical PolicyEcallantide (J1290) for Acute Hereditary Angioedema — Coverage CriteriaDefines medical benefit coverage criteria, quantity limits, and authorization period for ecallantide (injection) used to treat acute attacks of hereditary angioedema for members of Community-Care.All Community-Care updates
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Tool Description
Search Community-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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