EmblemHealth Coverage Criteria
Latest EmblemHealth coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-08Lyme Disease Intravenous TreatmentDefines medical necessity criteria, acceptable agents, exclusions, and coding for IV antibiotic therapy for members with confirmed Lyme disease; applies to providers requesting preauthorization from EmblemHealth.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Medical Technologies Database — Investigational, Unproven, HDE, and Transplant Case Management Coverage CriteriaThis document lists medical technologies, devices, and procedures that EmblemHealth considers investigational, unproven, or subject to special handling (including HDE and FEHB notes) and describes program-level transplant case management; it affects providers submitting precertification/coverage requests for EmblemHealth members, including transplant program referrals.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-10Breast Reduction MammoplastyClinical criteria and coverage guidance for breast reduction (reduction mammoplasty) including documentation, eligibility, and exclusions for EmblemHealth members undergoing the procedure.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-012026 EmblemHealth Formulary (US86) — Coverage CriteriaThis document lists covered prescription drugs, tiers, and formulary rules for EmblemHealth members and explains prior authorization, quantity limits, step therapy, and how to use the formulary.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-13Chemical PeelsClinical coverage criteria for chemical peel procedures, specifying when medium or deep peels are medically necessary and listing limitations/exclusions; applies to EmblemHealth members and treating providers submitting documentation for review.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-13Vertical Expandable Prosthetic Titanium RibGoverns medical necessity and coverage criteria for use of the Vertical Expandable Prosthetic Titanium Rib (VEPTR) in infants and children with thoracic insufficiency syndrome or rib/chest wall defects, for EmblemHealth members.All EmblemHealth updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-02-13Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases - Lab Benefit Program (LBM)Defines coverage criteria for laboratory biomarker tests (CSF and serum) used in diagnosis and differentiation of multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), and MOG-IgG-associated disease for EmblemHealth's Lab Benefit Program (LBM); applies to claims and providers submitting tests under the payer's reimbursement rules.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-23Glaucoma SurgeryClinical policy governing medical necessity and coverage criteria for surgical treatments for glaucoma (including laser trabeculoplasty, trabeculectomy, aqueous shunts, and certain microstents) for EmblemHealth members and affecting treating ophthalmologists and surgical providers.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-23Penile ImplantsMedical necessity and coverage criteria for surgical implantation, repair, removal, or replacement of penile prostheses for EmblemHealth members, and documentation/prior authorization expectations for providers.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01EmblemHealth 2026 Drug List (Large Group Generic Formulary) — Coverage CriteriaGoverns the covered prescription drugs, tiers, and utilization management (e.g., prior authorization, quantity limits, step therapy) for EmblemHealth large group plans; affects members, prescribing providers, and pharmacies using the plan's drug list.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01EmblemHealth Local 246 Prescription Drug Formulary (Coverage Criteria)This document is the EmblemHealth Local 246 prescription drug formulary describing covered drugs, tiers, utilization management (e.g., prior authorization, quantity limits, step therapy), and member/provider resources for plan members and prescribing providers.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Preventive Care and Screening Services — Coverage CriteriaGoverns coverage, frequency, and coding for preventive screenings, counseling, immunizations, breastfeeding equipment and related services for members under ConnectiCare/EmblemHealth plans, with distinctions for non‑grandfathered and grandfathered plans and network vs out‑of‑network providers.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Preventive Services & Screening — Coverage CriteriaDefines EmblemHealth coverage, coding, frequencies and limitations for preventive services and screenings (including immunizations, counseling, breastfeeding equipment and specific screening tests) for commercial and Medicaid members; applies to network providers and non-grandfathered plans unless otherwise noted.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Preventive Services & Screening — Coverage CriteriaDefines EmblemHealth coverage, cost-sharing, and coding for preventive services and screenings (commercial and Medicaid), including specific services, frequencies, and device benefits; applies to network providers and members of non-grandfathered and grandfathered plans as noted.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Preventive Services & Screening — Coverage CriteriaAll EmblemHealth updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-09-01Tecelra (afamitresgene autoleucel) coverage for synovial sarcomaDefines coverage, prior authorization, coding, indications, contraindications, and exclusions for Tecelra (afamitresgene autoleucel) for EmblemHealth members; applies to network ordering providers and multiple lines of business.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-07Encelto (revakinagene taroretcel-lwey) — Coverage Criteria for Macular Telangiectasia Type 2Clinical coverage policy governing use of the Encelto allogeneic encapsulated cell‑based gene therapy implant for adults with idiopathic macular telangiectasia type 2 (MacTel Type 2). Affects providers seeking authorization and reimbursement from EmblemHealth/ConnectiCare.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01EmblemHealth NYSHIP 2-Tier Prescription Drug Formulary (coverage criteria)Defines the list of covered outpatient prescription drugs, tier placement, and common utilization controls (PA, QL, ST, LA) for EmblemHealth NYSHIP 2-Tier members; intended for members, providers, and pharmacies using the NYS2 formulary.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Emrelis (telisotuzumab vedotin) IntravenousDefines EmblemHealth prior authorization, dosing limits, and medical necessity criteria for Emrelis (telisotuzumab vedotin) for adult patients with locally advanced or metastatic non-squamous NSCLC with high c-Met overexpression who have received prior systemic therapy.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-13Oncology (Injectable) - Bevacizumab Products Utilization Management Medical PolicyDefines prior authorization recommendations, coverage criteria, and dosing for bevacizumab products (Avastin, Alymsys, Mvasi, Vegzelma, Zirabev) for non-ophthalmic indications in Medicare Advantage members across specified service areas.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-11Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiotherapy (SBRT) and Proton Beam Therapy (PBT)Defines medical necessity criteria, covered indications, limitations/exclusions, applicable procedure (CPT/HCPCS) and ICD-10 diagnosis codes for SRS/SBRT and proton beam therapy for Commercial and Medicaid members (partial document - Part 1).All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Evolent Clinical Guideline 3140 for Cablivi TM (caplacizumab-yhdp)Defines accepted indications, clinical criteria, exclusions, contraindications, warnings, and billing code(s) for Cablivi (caplacizumab-yhdp) use in aTTP across EmblemHealth/Evolent lines of business. Describes continuation rules, evidence sources, and administrative responsibilities for medication requests.All EmblemHealth updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-06-13Therapeutic Drug Monitoring for 5‑Fluorouracil (5‑FU)This reimbursement policy governs coverage and limitations for therapeutic drug monitoring (TDM) of 5‑fluorouracil (5‑FU) for individuals receiving 5‑FU chemotherapy under EmblemHealth plans, including which specific tests meet or do not meet coverage criteria.All EmblemHealth updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-06-13Therapeutic Drug Monitoring for 5‑Fluorouracil - Lab Benefit Program (LBM)This reimbursement policy governs coverage and billing guidance for therapeutic drug monitoring (TDM) of 5‑fluorouracil for individuals receiving 5‑FU chemotherapy under the Lab Benefit Program (LBM), including which tests meet or do not meet coverage criteria.All EmblemHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-11Otoacoustic Emissions TestingClinical coverage criteria and coding guidance for otoacoustic emissions (OAE) screening and diagnostic testing for EmblemHealth members, including indications, limitations, and applicable procedure and diagnosis codes; intended for providers requesting authorization or submitting claims.All EmblemHealth updates
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Tool Description
Search EmblemHealth 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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