Delaware First Health Coverage Criteria
Latest Delaware First Health coverage criteria updates22
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Clinical Policy: Orthognathic SurgeryClinical policy governing medical necessity and coverage guidance for orthognathic (jaw) surgery for members of the Health Plan that adopted this policy.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-25Clinical Policy: External Diabetic Devices (Omnipod)Policy governs prior authorization and medical necessity criteria for Omnipod insulin delivery systems (Omnipod DASH, Omnipod 5, Omnipod GO) for Delaware First Health Medicaid members and describes initial and continued coverage requirements.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-25Crisaborole (Eucrisa) topical therapy — Coverage CriteriaDefines medical necessity criteria, prior authorization and continuation requirements for crisaborole (Eucrisa) topical treatment of mild to moderate atopic dermatitis for Delaware First Health members under the referenced policy.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-09-17Clinical Policy: Glecaprevir/Pibrentasvir (Mavyret)Clinical coverage policy governing medical necessity criteria, approval duration, and prescribing limitations for Mavyret (glecaprevir/pibrentasvir) for treatment of hepatitis C virus (HCV) in Delaware First Health members (Medicaid line of business). Applies to prescribers requesting prior authorization.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-12Enzalutamide (Xtandi) Coverage CriteriaDefines medical necessity and prior authorization criteria for enzalutamide (Xtandi) for prostate cancer indications for Delaware First Health members across Commercial, HIM, and Medicaid lines of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-17Glecaprevir/Pibrentasvir (Mavyret) — Clinical Coverage CriteriaClinical coverage policy governing use of the hepatitis C direct-acting antiviral combination glecaprevir/pibrentasvir (Mavyret) for members (including pediatric) under Delaware First Health Medicaid.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-17Sofosbuvir/Velpatasvir/Voxilaprevir (Vosevi) coverageDefines prior authorization, coverage criteria, and treatment conditions for Vosevi (sofosbuvir/velpatasvir/voxilaprevir) for Delaware First Health Medicaid members. Applies to initial and continued therapy, listing required documentation, alternative therapies, and contraindications.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-23Clinical Policy: Anti-Obesity MedicationsDefines Delaware First Health (Medicaid) coverage, medical necessity criteria, and prior authorization requirements for specified anti-obesity medications for adults and pediatric members, and for indications including weight loss, MASH, and prevention of MACE.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-09-16Clinical Policy: Elbasvir/Grazoprevir (Zepatier)Defines medical necessity criteria, prior authorization, and coverage rules for Zepatier (elbasvir/grazoprevir) for treatment of hepatitis C virus (HCV) infection for Delaware First Health (Medicaid); includes dosing by genotype, documentation requirements, step therapy preferences, and an appendix on managing missed therapy.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-08-16Etanercept (Enbrel) - Coverage Criteria and Prior AuthorizationClinical coverage and prior authorization criteria for Etanercept (Enbrel) for Delaware First Health Medicaid members, including initial and continuation therapy requirements across FDA‑approved indications.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-12-01Belumosudil (Rezurock) coverageCoverage and medical necessity criteria for belumosudil (Rezurock) for treatment of chronic graft-versus-host disease (cGVHD) and related authorization requirements for Delaware First Health lines of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-04-22Clinical Policy: Sacituzumab govitecan‑hziy (Trodelvy) coverageDefines medical necessity, prior authorization, and coverage criteria for sacituzumab govitecan‑hziy (Trodelvy) for Delaware First Health lines of business (Commercial, HIM/ICHRA, Medicaid). Applies to providers requesting coverage for the drug.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Pancrelipase (Creon, Pancreaze, Pertzye, Viokace, Zenpep) — Coverage CriteriaDefines medical necessity, initial and continued authorization criteria, dosing limits, and product availability for pancrelipase products for members under the Medicaid line of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-05-07Solriamfetol (Sunosi) coverageDefines medical necessity, prior authorization, and coverage criteria for solriamfetol (Sunosi) for treatment of excessive daytime sleepiness associated with narcolepsy or obstructive sleep apnea for Delaware First Health lines of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-03-01Omadacycline (Nuzyra) coverageDefines medical necessity criteria, dosing limits, and authorization requirements for omadacycline (Nuzyra) for adults with CABP or ABSSSI and guidance for other/ off-label uses within Delaware First Health lines of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-09-19Dipeptidyl Peptidase-4 (DPP-4) Inhibitors prior authorizationDefines prior authorization, coverage criteria, and continuation requirements for DPP-4 inhibitor medications for adults with type 2 diabetes mellitus under Delaware First Health (Medicaid). Applies to provider requests for listed DPP-4 products and certain combination products.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-01Apalutamide (Erleada) — Coverage CriteriaDefines medical necessity, prior authorization, and continuation criteria for apalutamide (Erleada) for Delaware First Health Medicaid members, including FDA-approved and select off‑label prostate cancer uses, and prescribing/step therapy expectations for providers.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2017-03-01Rivastigmine (Exelon) prior authorization and coverage criteriaDefines medical necessity criteria, dosing limits, and prior authorization requirements for rivastigmine (Exelon) products for Delaware First Health Medicaid members, including Alzheimer’s disease and Parkinson's disease dementia.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2017-01-01Clinical Policy: Romidepsin (Istodax) — Coverage CriteriaDefines medical necessity criteria, dosing limits, and authorization requirements for romidepsin (Istodax) for T‑cell lymphomas across Delaware First Health lines of business; affects prescribers, pharmacists, and prior authorization reviewers.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-06-01Pertuzumab (Perjeta) and pertuzumab-dpzb (Poherdy) coverageDefines medical necessity, prior authorization, and coverage criteria for pertuzumab (Perjeta) and its biosimilar pertuzumab-dpzb (Poherdy) for treatment of HER2-positive cancers for members of Delaware First Health across Commercial, HIM/ICHRA, and Medicaid lines of business.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2012-08-01Omega-3-Acid Ethyl Esters (Lovaza) CoverageDefines medical necessity and prior authorization criteria for coverage of omega-3-acid ethyl esters (Lovaza) for Medicaid members, primarily for treatment of severe hypertriglyceridemia in adults.All Delaware First Health updates
- Coverage CriteriaClinical/Medical PolicyMedical Record Collection Process — Coverage Criteria for Record RequestsGoverns Delaware First Health's process for requesting and collecting medical records from providers for HEDIS and other quality measure reporting to CMS and state agencies; applies to providers identified as a member's PCP or who submitted relevant claims/encounters.All Delaware First Health updates
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Tool Description
Search Delaware First 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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