Medimpact Coverage Criteria
Latest Medimpact coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Tretinoin prior authorization criteria (Kentucky Medicaid)Defines new prior authorization clinical criteria for tretinoin formulations for Kentucky Medicaid (Fee-for-Service and MCO) effective June 1, 2026; affects pharmacy providers, prescribers, and beneficiaries covered by Kentucky Medicaid.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-15Hypertonic saline prior authorization for Kentucky MedicaidEstablishes prior authorization requirements and coverage criteria for specified hypertonic saline NDCs for Kentucky Medicaid members (MCO and FFS); affects prescribers and pharmacies submitting PA requests to MedImpact for Kentucky Medicaid.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-19Immune globulins (IVIG, SCIG) pharmacy coverage criteriaDescribes Kentucky Medicaid pharmacy coverage and POS/prior authorization (PA) requirements for intravenous and subcutaneous immune globulin products, and what documentation is required for PA. Affects providers dispensing/administering IVIG or SCIG for Kentucky Medicaid members.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyBerdazimer (Zelsuvmi) and related dermatology coverage decisions (including Vykat XR and Andembry) - Coverage CriteriaDefines P&T Committee recommendations and prior authorization criteria for berdazimer (Zelsuvmi) topical antiviral for molluscum contagiosum and adds coverage rules for newly listed products (Vykat XR, Andembry) including age, quantity, prescriber and documentation requirements.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyBrensocatib (Brinsupri) and class-level PA updates — Coverage CriteriaDefines P&T recommendations and prior authorization criteria for Brinsupri (brensocatib) for non‑cystic fibrosis bronchiectasis and adds multiple new products with specified initial/renewal criteria and PA requirements.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyBrensocatib (Brinsupri) — coverage criteria for non‑cystic fibrosis bronchiectasisCriteria and coverage considerations for brensocatib (Brinsupri) as a non-PDL single-agent review for treatment of non-cystic fibrosis bronchiectasis; intended for providers prescribing or requesting prior authorization. Applies to MedImpact members covered under this payer's pharmacy review process.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyCobenfy™ (xanomeline–trospium) formulary recommendation for schizophreniaP&T Committee recommendations for placing Cobenfy™ (xanomeline with trospium) on the formulary as Non-Preferred within second‑generation antipsychotics; includes initial approval and renewal criteria for coverage of schizophrenia.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyCommissioner selections for Kentucky Preferred Drug List (PDL) — selected specialty drugsSummarizes the Commissioner of the Department for Medicaid Services' final Preferred Drug List selections and coverage criteria for several specialty drugs (vutrisiran/Amvuttra, sodium phenylbutyrate/taurursodiol/Relyvrio, eflapegrastim/Rolvedon, lenacapavir/Sunlenca) as reviewed by the P&T Committee on March 16, 2023; applies to Kentucky Medicaid formulary decisions and prescribers seeking prior authorization.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyCommissioner selections for preferred drugs (Kentucky)Summary of the Commissioner for the Department for Medicaid Services' Preferred Drug List selections and coverage criteria for several specialty and pharmacy agents affecting Medicaid members in Kentucky. Covers initial and renewal authorization criteria, age/quantity limits, and monitoring requirements for listed products.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyCommissioner selections for preferred prescription products (Kentucky) — PDL coverage criteria summarySummarizes the Commissioner for the Department for Medicaid Services' final Preferred Drug List (PDL) selections and associated coverage criteria for selected drugs/classes in Kentucky; intended for providers and pharmacy staff managing Medicaid prescription coverage.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyKentucky Medicaid Drug Review — P&T Agenda and Coverage OptionsLists drugs, proposed coverage criteria, and options for consideration to be reviewed by the Kentucky Department for Medicaid Services Pharmacy & Therapeutics Advisory Committee; affects Kentucky Medicaid drug coverage and prior authorization practices for the listed agents and classes.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyKentucky Medicaid Pharmacy & Therapeutics Advisory Committee — Special Meeting Agenda (coverage criteria)Agenda for the Kentucky Medicaid Pharmacy & Therapeutics Advisory Committee special meeting describing items to be reviewed, new products, therapeutic class recommendations, and procedural details for attendees and stakeholders.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyKentucky Medicaid drug review and coverage options (P&T agenda)Summarizes drug-specific coverage criteria, prior authorization and PDL (preferred drug list) status recommendations to be reviewed by MedImpact for the Kentucky Department for Medicaid Services; affects prescribers and pharmacy benefit administrators managing Kentucky Medicaid drug benefits.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew Products to Market — Preferred Drug List selections and PA criteriaGovernance of preferred drug list selections, approval durations, quantity limits, and prior authorization (PA) / clinical criteria for newly reviewed prescription products affecting Medicaid beneficiaries and prescribers.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew Products to Market — Preferred Drug List selections and coverage criteriaGoverns coverage designations, approval criteria, quantity limits, and prior authorization requirements for newly reviewed drugs and therapeutic classes affecting Medicaid members and prescribing providers.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew products to market — Preferred Drug List selections and coverage criteriaSummarizes PDL selections and establishes coverage, initial and renewal authorization criteria, quantity limits, and approval durations for several new specialty products affecting PAH, PNH, PH1, IBD, and related therapies for Medicaid managed by MedImpact.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew products to market — coverage criteria for select specialty and pharmacy drugsDefines coverage decisions, approval criteria, durations, age and quantity limits, and prescriber requirements for newly reviewed drugs added to the PDL or non‑PDL list affecting Medicaid populations reviewed by the P&T committee.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew products to market — pharmacy & specialty drug coverage criteriaGoverns initial approval, renewal, age and quantity limits, and clinical criteria for several newly marketed specialty and pharmacy drugs and their PDL status for members covered by MedImpact's managed programs.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew specialty drug PDL additions and coverage criteriaThis document summarizes new products added to the Preferred Drug List (PDL) with their formulary status, approval durations, and specific initial and renewal coverage criteria affecting prescribers, pharmacists, and prior authorization staff.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew specialty drug additions to PDL — coverage criteria for Vowst, Bimzelx, Velsipity, Omvoh, and related agentsDefines initial and renewal coverage criteria, age and quantity limits, approval durations, and prescribing requirements for newly reviewed specialty drugs added to the Preferred Drug List (PDL). Affects prescribers and pharmacists managing Medicaid-covered specialty medications.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyNew specialty drug product coverage additions — Initial and renewal criteria, PA and documentation requirementsDefines initial and renewal coverage criteria, prescriber and documentation requirements, age and quantity limits, and approval durations for newly marketed specialty drugs reviewed by the P&T Advisory Committee. Applies to MedImpact-managed Medicaid pharmacy benefits and providers seeking coverage for the listed products.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyP&T recommendations for Alyftrek and related CFTR modulators — coverage criteria summarySummarizes the P&T Advisory Committee recommendations (April 15, 2025) for Alyftrek and related CFTR modulators, including initial and renewal coverage criteria, documentation, age and quantity limits, and formulary placement; affects Medicaid pharmacy coverage pending state review.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyP&T recommendations for new pharmacy products (Zunveyl, Qfitlia)Summarizes P&T Committee recommendations (July 15, 2025) for placement and coverage criteria for new products Zunveyl® and Qfitlia™ including formulary status, approval duration, approval criteria, and quantity limits; intended for MedImpact plan decisioning and provider/pharmacy stakeholders.All medimpact updates
- Coverage CriteriaClinical/Medical PolicyPalsonify (paltusotine) — coverage criteria for acromegalyDefines initial authorization criteria and approval duration for Palsonify (paltusotine) for adults with acromegaly who had an inadequate response to surgery or for whom surgery is not an option; intended for prescribers and pharmacy prior authorization reviewers.All medimpact updates
- Coverage CriteriaClinical/Medical PolicySingle Agent Reviews — Pharmacy & Specialty Drugs coverage criteriaThis document lists single-agent pharmacy review agenda items and proposed coverage/options for consideration for various new and existing specialty and dermatologic drugs presented to the Pharmacy & Therapeutics Advisory Committee; it affects prescribers, pharmacy reviewers, and payer policy decision-makers.All medimpact updates
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Tool Description
Search Medimpact 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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