ConnectiCare Coverage Criteria
Latest ConnectiCare coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-15Pancreatic Enzyme Testing for Acute PancreatitisThis policy governs ConnectiCare coverage and reimbursement criteria for pancreatic enzyme and related biomarker testing used in evaluating acute pancreatitis. Coverage criteria do not apply to Exchange Plans for dates of service on or after January 1, 2026.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-11Gender-Affirming SurgeryThis policy governs ConnectiCare coverage and prior authorization review for puberty suppression, cross-sex hormone therapy, gender-affirming genital and breast surgery, and related procedures. It applies to members requesting medically necessary treatment for gender dysphoria, subject to the member’s benefit plan and applicable legal requirements.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-11Non-Emergent Ambulance ServicesThis policy governs medical necessity criteria for non-emergency ambulance transportation for ConnectiCare Medicare and commercial members in Connecticut.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-12Automatic External DefibrillatorsThis policy governs coverage of wearable and nonwearable automatic external defibrillators for ConnectiCare members with a DME benefit who are at high risk for sudden cardiac death. Coverage requires the applicable clinical criteria and supporting clinical documentation for prior authorization.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-12Continuous Passive Motion DevicesThis policy governs home continuous passive motion device coverage for members with a Durable Medical Equipment benefit, including covered postoperative and infant clubfoot indications, medical necessity limits, prior authorization documentation, and applicable procedure and diagnosis codes. Coverage is subject to the member’s benefit plan and the policy’s clinical criteria.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-12Home Birth Midwifery ServicesCoverage and medical-necessity review for certified midwives providing home birth services throughout pregnancy, labor, birth, immediate postpartum care, and neonatal care up to 6 weeks, subject to credentialing, documentation, high-risk criteria, and timely hospital transfer capability.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-11Amyotrophic Lateral Sclerosis (ALS): Edaravone Coverage CriteriaThis policy governs coverage and prior authorization for intravenous and oral edaravone products used to treat amyotrophic lateral sclerosis (ALS), including clinical eligibility, documentation, prescriber, dosing, continuation, and administration requirements.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-11Leqembi (lecanemab-irmb) Coverage CriteriaThis policy governs prior authorization and coverage criteria for lecanemab-irmb products used to treat Alzheimer's disease in ConnectiCare commercial members, including eligibility, documentation, continuation requirements, dosing, prescriber qualifications, and administration settings.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-11Riluzole (Rilutek/Tiglutik/Exservan)This policy governs prior authorization and coverage criteria for oral riluzole products used to treat amyotrophic lateral sclerosis (ALS) under the pharmacy benefit.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-06Viltepso (viltolarsen) Coverage CriteriaCoverage determinations for Viltepso (viltolarsen), including use for Duchenne muscular dystrophy and other indications; the policy considers Viltepso not medically necessary because clinical benefit has not been established, subject to benefit eligibility and plan terms.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-06Vyondys 53 (golodirsen) Coverage CriteriaThis policy governs coverage determinations for Vyondys 53 (golodirsen) for members with Duchenne muscular dystrophy. The drug is considered not medically necessary for all indications because clinical benefit has not been established.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-06Xenazine (tetrabenazine) Coverage CriteriaPrior authorization coverage of tetrabenazine/Xenazine for Huntington disease chorea, moderate-to-severe tardive dyskinesia, and Tourette syndrome, subject to condition-specific documentation, prescriber qualifications, dose limits, and contraindication review.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-30Emflaza (deflazacort) Coverage CriteriaCoverage determinations for oral deflazacort products, including Emflaza, Jaythari, Kymbee, and Pyqui, primarily for Duchenne muscular dystrophy; the policy considers deflazacort not medically necessary for all indications.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-30Myalept (metreleptin) Coverage CriteriaPrior authorization coverage for Myalept subcutaneous injection for complications of leptin deficiency in members with congenital or acquired generalized lipodystrophy, including initial and continuation criteria, documentation requirements, dosing limits, and administration setting.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-30Santyl (collagenase) Coverage CriteriaCoverage and prior authorization requirements for topical Santyl (collagenase) used to debride chronic dermal ulcers and severely burned areas under the applicable pharmacy or medical benefit.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-30Tzield (teplizumab-mzwv) Coverage CriteriaThis policy governs prior authorization and coverage of intravenous Tzield (teplizumab-mzwv) to delay the onset of Stage 3 type 1 diabetes in adults and pediatric patients age 8 years and older with Stage 2 type 1 diabetes. It applies to providers requesting coverage under the member's applicable pharmacy or medical benefit.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-08Implantable Cardioverter DefibrillatorsThis policy governs medical necessity and prior authorization for FDA-approved transvenous and subcutaneous implantable cardioverter defibrillators, including adult and pediatric implantation, surveillance, replacement, and related CRT/ICD use. Coverage depends on specified clinical criteria and applicable benefit-plan terms.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-08Posterior Tibial Nerve Stimulation for Voiding DysfunctionThis policy governs medical-necessity and coverage criteria for percutaneous posterior tibial nerve stimulation (PTNS) for overactive bladder and related voiding symptoms in ConnectiCare members. It also identifies excluded indications and noncovered implantable and wearable tibial nerve stimulation devices.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Dalvance (dalbavancin) Coverage CriteriaThis policy governs prior authorization and medical-necessity coverage for intravenous Dalvance (dalbavancin) used to treat acute bacterial skin and skin structure infections and adult osteomyelitis. It applies to providers requesting coverage, subject to member benefit eligibility and the clinical criteria in the policy.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-27Antipsychotics Coverage CriteriaCoverage and prior authorization criteria for oral and transdermal atypical antipsychotic drugs, including FDA-approved and compendia-supported uses, under the pharmacy benefit.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-27Cytomegalovirus Prophylaxis Post Solid Organ TransplantThis policy governs prior authorization and coverage of Cytogam (cytomegalovirus immune globulin intravenous [human]) for CMV prophylaxis after specified solid organ transplantation and for adjunctive treatment of CMV pneumonitis. It applies to members receiving the drug under the pharmacy or medical benefit, subject to benefit eligibility and the clinical criteria in the policy.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-13Blepharoplasty and Eyelid Ptosis RepairThis policy governs ConnectiCare coverage and prior authorization for blepharoplasty, blepharoptosis repair, brow lift, eyelid reconstruction, and related eyelid procedures. Functional or reconstructive procedures may be covered when specified medical-necessity criteria and documentation are met; procedures performed solely for cosmetic appearance are not medically necessary.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-13Lidocaine Patch Coverage CriteriaPharmacy-benefit coverage and prior authorization for topical lidocaine patches used for post-herpetic neuralgia, cancer-related neuropathy, or diabetic neuropathy, including initial and continuation therapy.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-04Drug and Biologic Coverage Criteria: Antineoplastic Drugs and BiologicsCoverage determinations for antineoplastic drugs and biologics for ConnectiCare commercial members, including medical necessity, prior authorization, preferred-product and biosimilar requirements, documentation, continuation, dosing, and state-specific utilization-management provisions.All ConnectiCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-04Xermelo (telotristat ethyl) Coverage for Carcinoid Syndrome DiarrheaThis policy governs pharmacy benefit coverage and prior authorization for Xermelo (telotristat ethyl) used to treat carcinoid syndrome diarrhea in adults. Coverage requires documented disease, inadequate response to antidiarrheals, ongoing somatostatin analog therapy, and fulfillment of clinical and prescriber requirements.All ConnectiCare updates
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Tool Description
Search ConnectiCare 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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