Meridian Coverage Criteria
Latest Meridian coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01COVID-19 Test Quantity LimitDefines medical necessity and approval criteria for coverage of COVID-19 test kits in excess of the standard allowance for Meridian (Medicaid) members, and documents required from providers to support such requests.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Actimmune (interferon gamma-1b) coveragePrior authorization policy for Actimmune covering FDA-approved indications and specific approval criteria for chronic granulomatous disease and malignant osteopetrosis; applies to Meridian Health Plan products requiring PA. Affects prescribers and patients seeking coverage for Actimmune.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Oral and Enteral FormulaDefines medical necessity criteria, coding guidance, and coverage rules for oral and enteral nutrition products (standard, specialized, elemental/semi-elemental, metabolic, and specialty infant) for Meridian members; applies to Medicaid line of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Lovotibeglogene autotemcel (Lyfgenia) gene therapy coverageDefines medical necessity, authorization, and coverage criteria for Lyfgenia (lovotibeglogene autotemcel) for members (Medicaid line of business) including initial and continuation criteria and documentation requirements for providers.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Finerenone (Kerendia) — Coverage Criteria for CKD with Type 2 DiabetesDefines medical necessity and prior authorization criteria for finerenone (Kerendia) for adult members with chronic kidney disease associated with type 2 diabetes under Meridian (Medicaid) lines of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Clinical Policy: Resmetirom (Rezdiffra)Defines medical necessity and authorization criteria for coverage of resmetirom (Rezdiffra) for adults with noncirrhotic metabolic dysfunction-associated steatohepatitis (MASH/NASH) with stage F2–F3 fibrosis under Meridian Health Plan (Medicaid). Applies to prescribers and reviewers processing benefit requests.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Agents for Epilepsy and SeizuresDefines prior authorization requirements, approval durations, and coverage criteria for specified antiepileptic agents for members covered by Meridian Health Plan (Medicaid line of business referenced). Affects providers requesting coverage for listed seizure/epilepsy medications.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-20Tirzepatide (Zepbound)Defines medical necessity, initial and continuing coverage criteria, dosing limits, exclusions, and documentation requirements for Zepbound (tirzepatide) when used to treat moderate to severe obstructive sleep apnea in Meridian Illinois Medicaid members.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-12-01Axitinib (Inlyta) — Coverage and Prior AuthorizationDefines medical necessity criteria, prior authorization requirements, and approval durations for axitinib (Inlyta) for Medicaid members, including FDA-approved and selected off-label indications and continuation criteria.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-22Clinical Policy: Amantadine ER (Gocovri)Defines medical necessity, prior authorization, and coverage criteria for Gocovri (amantadine ER) for dyskinesia and 'off' episodes in Parkinson's disease for Meridian lines of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Cenobamate (Xcopri) for partial-onset seizuresMedical necessity and coverage criteria for cenobamate (Xcopri) when used to treat partial-onset (focal) seizures in adults under Meridian Medicaid and other Meridian-affiliated health plans.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-16Treprostinil (Orenitram, Remodulin, Tyvaso, Tyvaso DPI) coverageDefines medical necessity, prior authorization, and coverage criteria for treprostinil formulations for treatment of pulmonary arterial hypertension (PAH) and pulmonary hypertension associated with interstitial lung disease (PH-ILD) for Meridian lines of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Infliximab (Remicade, Inflectra, Renflexis, Avsola, Zymfentra)Medical necessity and prior authorization criteria for infliximab and listed biosimilars for Meridian Medicaid members across labeled inflammatory indications.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Tasimelteon (Hetlioz) therapy coverageDefines Medicaid coverage criteria, dosing, and authorization requirements for tasimelteon (Hetlioz and Hetlioz LQ) for non-24-hour sleep-wake disorder and nighttime sleep disturbances in Smith-Magenis Syndrome.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-02-01Respiratory syncytial virus vaccine (Abrysvo, Arexvy, mResvia)Defines medical necessity and coverage criteria for Abrysvo, Arexvy, and mResvia immunizations for Meridian Illinois Medicaid pharmacy benefits, including initial approval criteria, contraindications, dosing, and documentation expectations.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-01Cannabidiol (Epidiolex) coverageThis policy governs medical necessity criteria, approvals, and coverage parameters for Epidiolex (cannabidiol) for treatment of seizures associated with Dravet syndrome, Lennox-Gastaut syndrome, and tuberous sclerosis complex for Meridian Health Plan (Illinois Medicaid line of business). It affects providers requesting prior authorization for Epidiolex for covered members.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Betamethasone Dipropionate Spray (Sernivo)Policy governing medical necessity criteria, prior authorization, and coverage conditions for betamethasone dipropionate 0.05% spray (Sernivo) for Meridian Health Plan Medicaid members.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Clinical Policy: Deucravacitinib (Sotyktu)Defines medical necessity and prior authorization criteria for coverage of deucravacitinib (Sotyktu) for adults with moderate-to-severe plaque psoriasis under Meridian Health Plan (Medicaid line of business). Applies to providers requesting coverage for members.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Etanercept (Enbrel) — Clinical PolicyDefines medical necessity criteria, prior authorization and continuation requirements for etanercept (Enbrel) for Meridian Health Plan Medicaid members across FDA‑approved indications and certain other uses.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Factor VIII (Human, Recombinant) prior authorization and coverageGoverns prior authorization, medical necessity, and coverage criteria for factor VIII products (human and recombinant) for treatment of hemophilia A and acquired hemophilia A under Meridian's Medicaid line of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-01Galcanezumab-gnlm (Emgality) coverageDefines medical necessity, prior authorization, and coverage criteria for Emgality (galcanezumab-gnlm) for migraine prophylaxis and episodic cluster headache for Meridian Health Plan Medicaid line of business.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-16Adefovir (Hepsera) coverage criteriaPolicy governing medical necessity and prior authorization criteria for Hepsera (adefovir) for members (Medicaid line of business), including initial and continuation therapy requirements and dosing limits.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-10-01Inhaled Agents for Asthma and COPDDefines prior authorization requirements, medical necessity criteria, and coverage parameters for inhaled corticosteroids, bronchodilators, and combination inhalers used to treat asthma and chronic obstructive pulmonary disease (COPD) for Meridian members (Illinois Medicaid line of business noted).All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-01Clinical Policy: Sarilumab (Kevzara)Defines Meridian Health Plan medical necessity, dosing, clinical criteria appendices, contraindications, boxed warnings, and product availability for sarilumab (Kevzara). Applies to providers requesting coverage for sarilumab for Meridian members.All meridian updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-01Clozapine Orally Disintegrating Tablet (ODT)Defines medical necessity and coverage criteria for clozapine ODT for members under the Medicaid line of business, including initial and continued therapy requirements and dosing limits.All meridian updates
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Tool Description
Search Meridian 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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