North Carolina Medicaid Coverage Criteria
Latest North Carolina Medicaid coverage criteria updates16
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Medicaid Outpatient Pharmacy Prior Approval Criteria: GLP-1 Receptor Agonists and CombinationsThis policy governs North Carolina Medicaid outpatient pharmacy prior approval, coverage criteria, continuation requirements, and quantity limits for GLP-1 receptor agonists and combination products for eligible beneficiaries, including EPSDT provisions for beneficiaries under 21.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-01Outpatient Pharmacy Prior Approval Criteria: SGLT2 Inhibitors and CombinationsThis North Carolina Medicaid outpatient pharmacy prior approval policy governs coverage of listed SGLT2 inhibitor and combination products for eligible Medicaid beneficiaries. It establishes initial and continuation coverage criteria for preferred and non-preferred products, including qualifying diagnoses, metformin-related requirements, preferred-product trials, and renewal documentation.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-07-01NC Medicaid Outpatient Pharmacy Prior Approval Criteria Systems (CGM) and Related SuppliesThis policy governs North Carolina Medicaid outpatient pharmacy prior approval and coverage criteria for FDA-classified therapeutic continuous glucose monitoring systems and supplies, including special EPSDT considerations for beneficiaries under 21 years of age.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-02-25Outpatient Pharmacy Prior Approval Criteria: Topical AntihistaminesPrior approval coverage criteria for topical doxepin used for short-term management of moderate pruritus in adults with atopic dermatitis or lichen simplex chronicus.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-27Kevzara coverage for rheumatoid arthritisThis policy governs NC Medicaid outpatient pharmacy prior approval for Kevzara, a systemic immunomodulator, in beneficiaries with rheumatoid arthritis. It establishes clinical prerequisites, preferred-product sequencing, concurrent biologic restrictions, and approval duration.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-06-27NC Medicaid Outpatient Pharmacy Prior Approval Criteria: ArcalystThis policy governs North Carolina Medicaid outpatient pharmacy prior approval for Arcalyst (rilonacept), including diagnosis-specific clinical criteria, safety screening requirements, and authorization limits.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-01-21NC Medicaid Outpatient Pharmacy Prior Approval Criteria: CosentyxThis policy governs North Carolina Medicaid prior approval for Cosentyx, a systemic anti-psoriatic agent, for specified inflammatory and psoriatic conditions. It applies to eligible NC Medicaid beneficiaries and establishes diagnosis-specific clinical criteria, screening requirements, biologic therapy restrictions, and approval duration.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2014-11-01Crinone 8% Gel (progesterone) Coverage CriteriaThis policy governs North Carolina Medicaid outpatient pharmacy prior approval for Crinone 8% Gel (progesterone), subject to beneficiary enrollment and eligibility-related service restrictions.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2014-08-15NC Medicaid Outpatient Pharmacy Prior Approval Criteria — EnbrelThis policy governs North Carolina Medicaid prior approval for Enbrel, a systemic immunomodulator and anti-inflammatory tumor necrosis factor inhibitor. It applies to eligible NC Medicaid beneficiaries and establishes diagnosis-specific clinical criteria, screening requirements, treatment history requirements, and duration limits.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyEff. 2002-03-04Outpatient Pharmacy Prior Approval Criteria: Growth HormonesThis policy governs North Carolina Medicaid and NC Health Choice prior approval and coverage criteria for outpatient growth hormone therapies, including somatropin, mecasermin, and tesamorelin.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyJuxtapid (lomitapide) Coverage Criteria for Homozygous Familial HypercholesterolemiaThis policy governs North Carolina Medicaid outpatient pharmacy prior approval for Juxtapid (lomitapide) in eligible Medicaid beneficiaries. Coverage is limited to beneficiaries with homozygous familial hypercholesterolemia who meet age, REMS, concomitant therapy, pregnancy testing, and liver-monitoring requirements.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyNC Medicaid Outpatient Pharmacy Prior Approval Criteria — AvsolaThis policy governs NC Medicaid prior approval and coverage criteria for Avsola, an anti-inflammatory tumor necrosis factor inhibitor, for specified inflammatory and autoimmune conditions, including EPSDT provisions for beneficiaries under 21.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyNC Medicaid Outpatient Pharmacy Prior Approval Criteria — XeljanzThis policy governs NC Medicaid prior approval and coverage criteria for Xeljanz tablets and oral solution for selected systemic inflammatory and autoimmune conditions.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyNC Medicaid Outpatient Pharmacy Prior Approval Criteria: CimziaThis policy governs NC Medicaid outpatient pharmacy prior approval for Cimzia, a systemic immunomodulator used for specified inflammatory diseases. It establishes diagnosis-specific clinical criteria, preferred-drug step therapy, safety screening, concurrent biologic restrictions, and authorization duration.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyPartners Individual Rehabilitation, Coordination, and Support (IRCS) ServicesThis policy governs North Carolina Medicaid coverage and delivery requirements for Partners Individual Rehabilitation, Coordination, and Support services for adults age 18 and older with serious and persistent mental illness and/or substance use disorder.All North Carolina Medicaid updates
- Coverage CriteriaClinical/Medical PolicyPsychosocial Rehabilitation During DisasterThis policy governs an alternative or in-lieu-of Psychosocial Rehabilitation service for adults with mental health diagnoses during declared state or national disasters or emergencies when regular in-person services cannot be safely provided. It establishes eligible populations, remote and in-person service delivery, authorization, clinical criteria, documentation, staffing, billing, and utilization limits.All North Carolina Medicaid updates
1–16 of 16
1 / 1
Tool Description
Search North Carolina Medicaid 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.
Coverage Criteria by Payer
Go deeper
Explore OpenPayer Data
Coverage policies are updated every day. Follow payer coverage policy updates in the live policy feed, or browse all CPT, HCPCS and DRG billing codes.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.