Molina Healthcare Coverage Criteria
- Molina Healthcare prior authorization
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Latest Molina Healthcare coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-24Keveyis (dichlorphenamide) Coverage CriteriaPrior authorization and pharmacy benefit coverage for oral dichlorphenamide products used to treat primary hyperkalemic or hypokalemic periodic paralysis and related variants, subject to clinical, prescriber, age, quantity, and safety requirements.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-19Elfabrio for Fabry DiseaseCoverage and prior authorization for intravenous Elfabrio (pegunigalsidase alfa-iwxj) in adults with confirmed Fabry disease under the pharmacy or medical benefit, subject to eligibility and clinical criteria.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-30Supprelin LA (histrelin acetate) Implant Coverage CriteriaCoverage and prior authorization requirements for Supprelin LA, a subcutaneous histrelin acetate implant used to treat children with central precocious puberty.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-30Thiola (tiopronin) Coverage CriteriaPrior authorization coverage for oral tiopronin products used to prevent cystine stone formation in adults and pediatric members with severe homozygous cystinuria, including initial and continuation criteria, documentation requirements, age restrictions, quantity limits, and pharmacy self-administration.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-30Zoladex (goserelin acetate) Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization requirements for Zoladex (goserelin acetate) for prostate cancer, breast cancer, endometriosis, dysfunctional uterine bleeding or uterine leiomyomas, and prevention of chemotherapy-induced premature ovarian insufficiency. It applies to providers requesting coverage for eligible members, subject to the member’s benefit plan and the clinical criteria in this policy.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-11Vtama (tapinarof) Cream Coverage CriteriaCoverage and prior authorization requirements for topical Vtama (tapinarof) cream for plaque psoriasis and atopic dermatitis, including diagnosis, age, clinical response, documentation, prescriber, quantity, and continuation criteria.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-30Tzield (teplizumab-mzwv) Coverage CriteriaThis policy governs prior authorization and coverage of intravenous Tzield for eligible adults and pediatric members aged 8 years and older with Stage 2 type 1 diabetes when prescribed by or in consultation with a board-certified endocrinologist and clinical criteria are met.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Prevymis (letermovir) Coverage CriteriaThis policy governs prior authorization coverage for oral or intravenous Prevymis used to prevent cytomegalovirus infection or disease in eligible hematopoietic stem cell transplant and kidney transplant recipients.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-13Redemplo (plozasiran) Coverage CriteriaCoverage and prior authorization requirements for Redemplo (plozasiran) used with diet to reduce triglycerides in adults with familial chylomicronemia syndrome.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-28Saphnelo (anifrolumab-fnia) Drug and Biologic Coverage CriteriaGoverns prior authorization and coverage of intravenous Saphnelo for adults with moderate to severe systemic lupus erythematosus receiving standard therapy, including clinical criteria, documentation, prescriber qualifications, dosing, and administration-site requirements.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-17Leqselvi (deuruxolitinib) coverage for severe alopecia areataThis policy governs prior authorization and coverage requirements for oral Leqselvi (deuruxolitinib) in adults with severe alopecia areata, including clinical severity, prior treatment, safety screening, and specialist documentation requirements.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-17Nulojix (belatacept) Coverage for Kidney Transplant Rejection ProphylaxisPrior authorization and coverage criteria for intravenous Nulojix (belatacept) to prevent organ rejection in adult kidney transplant recipients, requiring transplant documentation, specified concomitant immunosuppression, EBV seropositivity, and transplant specialist or nephrologist involvement.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Iluvien (fluocinolone acetonide intravitreal implant) Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization requirements for Iluvien administered for diabetic macular edema or non-infectious posterior uveitis. Coverage depends on benefit eligibility, documented medical necessity, applicable clinical criteria, and required provider documentation.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Iluvien (fluocinolone acetonide intravitreal implant) Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization requirements for Iluvien in adults with diabetic macular edema or non-infectious posterior segment uveitis.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Kisunla (donanemab-azbt) Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization for intravenous Kisunla used to treat Alzheimer's disease. It applies to members meeting the specified age, diagnostic, clinical, prescriber, monitoring, and administration requirements.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-10-15Cardiovascular Disease Risk AssessmentDefines Molina Healthcare's coverage policy for laboratory and biomarker testing used to assess cardiovascular disease (CVD) risk for adults, including which tests meet or do not meet coverage criteria and recommended frequencies.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-17Izervay (avacincaptad intravitreal) Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization for intravitreal Izervay (avacincaptad) used to treat geographic atrophy secondary to age-related macular degeneration. It applies to members meeting the documented clinical, prescriber, age, administration, and continuation requirements.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Biomarker Testing for Autoimmune Rheumatic DiseaseDefines Molina Healthcare's coverage criteria and limitations for antinuclear antibody (ANA), extractable nuclear antigen (ENA) panels, rheumatoid arthritis biomarkers (RF, anti‑CCP), dsDNA, and other biomarker panels used in diagnosis and monitoring of systemic autoimmune rheumatic diseases for covered individuals.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Helicobacter pylori TestingDefines Molina Healthcare's coverage criteria and limitations for diagnostic and eradication testing for Helicobacter pylori infection for covered individuals, including recommended test modalities and age-specific indications.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Human Immunodeficiency Virus (HIV)Defines Molina Healthcare's coverage criteria and limitations for HIV screening, nucleic acid testing, viral load monitoring, and genotypic/phenotypic resistance testing for affected individuals; applies to covered individuals under Molina benefits and references Medicare/Medicaid specifications in the policy.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-07-01Lyme Disease TestingDefines Molina Healthcare's coverage criteria and limitations for laboratory testing used to diagnose Lyme disease, including serologic algorithms, molecular methods, proprietary tests, and tick testing; applies to Molina members per their benefit coverage.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-28Kisunla (donanemab-azbt) Coverage CriteriaCoverage and prior authorization requirements for intravenous Kisunla (donanemab-azbt) for members with Alzheimer's disease under the applicable pharmacy or medical benefit.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-28Tysabri (natalizumab) Coverage CriteriaCoverage and prior authorization requirements for Tysabri in adults with relapsing forms of multiple sclerosis or moderately to severely active Crohn's disease, including initial and continuation criteria, documentation, safety, and authorization requirements.All Molina Healthcare updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2025-04-01Diabetes Mellitus Testing (A1c, FPG, OGTT) - Coverage and PaymentDefines Molina Healthcare's coverage criteria and limitations for diagnostic and monitoring tests for diabetes mellitus (A1c, fasting plasma glucose, and oral glucose tolerance testing) across patient populations and clinical scenarios.All Molina Healthcare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-08Linezolid Coverage CriteriaThis policy governs Molina Healthcare coverage and prior authorization requirements for Zyvox (linezolid) administered orally or intravenously for FDA-approved or compendia-supported bacterial infections, subject to medical necessity, safety, specialist, dosing, and duration criteria.All Molina Healthcare updates
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Tool Description
Search Molina Healthcare 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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