Highmark Pennsylvania Coverage Criteria
Latest Highmark Pennsylvania coverage criteria updates6
- Coverage CriteriaClinical/Medical PolicyEff. 2016-09-26Sipuleucel‑T (Provenge) for Metastatic Castrate‑Resistant Prostate CancerDefines Highmark Pennsylvania coverage criteria for sipuleucel‑T (Provenge) for adults with metastatic castrate‑resistant prostate cancer and operational payment/applicability rules for providers and claims.All Highmark Pennsylvania updates
- Coverage CriteriaClinical/Medical PolicyCOPD Management program — Coverage CriteriaDefines Highmark Pennsylvania's COPD Management program offering virtual 1:1 coaching, digital tools, clinician collaboration, and education for eligible members with COPD. Affects clinicians, referring providers, and Highmark members enrolled in specified plan types.All Highmark Pennsylvania updates
- Coverage CriteriaClinical/Medical PolicyIn Vitro Fertilization (IVF) coverage criteriaForm and criteria governing prior authorization and medical necessity determination for IVF services for Highmark/Blue Cross Blue Shield Delaware members; affects providers requesting IVF coverage.All Highmark Pennsylvania updates
- Coverage CriteriaClinical/Medical PolicyMedication prior authorization form for Wegovy (coverage criteria)A payer-specific prior authorization form used by providers to request coverage for Wegovy (semaglutide) and collect required member, provider, medication, and clinical information to support medical necessity determinations. Applies to providers submitting authorization requests to Highmark in the covered service regions.All Highmark Pennsylvania updates
- Coverage CriteriaClinical/Medical PolicyTumor marker and somatic molecular testing for cancerCoverage guidance for tumor marker and somatic molecular testing associated with common metastatic cancers, specifying tests tied to therapeutic decisions (companion diagnostics) and prognostic markers. Applies to Highmark Pennsylvania members and providers ordering tumor marker molecular tests.All Highmark Pennsylvania updates
- Coverage CriteriaClinical/Medical PolicyVirtual Pelvic Health (Bloom by Sword) — Coverage CriteriaDefines Highmark Pennsylvania's offering of Sword Health's virtual pelvic health program (Bloom) including eligibility, included components, exclusions, and enrollment instructions for members and referring providers.All Highmark Pennsylvania updates
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Search Highmark Pennsylvania 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.
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