Oklahoma Health Care Authority Coverage Criteria
Latest Oklahoma Health Care Authority coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-15Nyvepria and Stimufend (pegfilgrastim-apgf and pegfilgrastim-fpgk) Approval CriteriaThis policy governs prior authorization and coverage criteria for Nyvepria and Stimufend for SoonerCare members, requiring an FDA-approved diagnosis and a patient-specific, clinically significant reason preferred pegfilgrastim products cannot be used.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-01Eyeglasses Replacement for ChildrenThis guideline governs medical-necessity review and prior authorization for replacement or additional eyeglasses, lenses, and frames for children enrolled in the Oklahoma Health Care Authority program. Prior authorization is required when a child needs more than two pairs within a 12-month period.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-06Cough Assist Device CoverageThis guideline governs medical necessity and prior authorization for cough assist devices and related interfaces for Oklahoma Medicaid members. It defines initial coverage criteria, continued rental requirements, documentation obligations, and billing limitations.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-02Pediatric Speech-Language Evaluation Coverage CriteriaThis guideline governs medical-necessity and prior-authorization requirements for pediatric speech-language pathology evaluations, including evaluations of fluency, speech sound production, language, voice, and resonance. It applies to members ages 0 through 20 at the time of evaluation and establishes eligibility, documentation, evaluation-report, and continuation requirements.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-03-25Cosmetic and Reconstructive ProceduresThis OHCA guideline establishes medical-necessity and prior-authorization requirements for cosmetic and reconstructive surgical procedures for Oklahoma Medicaid fee-for-service members and providers.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-06-10Actinotherapy for AdultsThis guideline governs medical necessity and prior authorization for office- or clinic-based phototherapy using UVA and/or UVB, primarily for adults with cutaneous T-cell lymphoma or prurigo nodularis. Authorization is required for members age 21 years and older; children age 0–20 years do not require authorization for the listed service.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyAggrenox (aspirin/dipyridamole extended-release) Approval CriteriaThis policy governs SoonerCare reimbursement and prior authorization requirements for Aggrenox in adult members requiring prevention of recurrent thromboembolic stroke. Coverage requires an FDA-approved indication, age 18 or older, and patient-specific clinical justification for using Aggrenox instead of immediate-release dipyridamole with over-the-counter aspirin.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyAnnual Review of Propoxyphene ProductsThis document governs prior authorization approval criteria and quantity limits for selected propoxyphene products administered through the Oklahoma Health Care Authority. It also summarizes utilization and prescriber/member trends for propoxyphene products in fiscal year 2008.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyBariatric Surgery Coverage CriteriaThis guideline establishes OHCA medical-necessity, provider, program, evaluation, prior-authorization, and continued-coverage requirements for bariatric surgery. It applies to members ages 15 through 65 who are being evaluated for, undergoing, or receiving follow-up care related to bariatric surgery.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyBrovana (arformoterol tartrate) Coverage CriteriaThis Oklahoma Health Care Authority annual review governs coverage and prior authorization for Brovana (arformoterol tartrate) for adult members with COPD, chronic bronchitis, or emphysema. It maintains the existing approval criteria and quantity limit, with no changes recommended.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyBrovana (arformoterol tartrate) Coverage CriteriaThis annual review governs prior authorization and quantity limits for Brovana nebulized therapy for Oklahoma Health Care Authority members. It applies to adults with COPD, chronic bronchitis, or emphysema who meet the stated prior-treatment or clinical-exception criteria.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyCurrent Prior Authorization of Plavix and EffientThis policy governs Oklahoma Medicaid prior authorization requirements for Plavix (clopidogrel) and Effient (prasugrel), including covered cardiovascular indications, exclusions, approval durations, and continuation requirements. The first 90 days of therapy do not require prior authorization.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyDigital Analysis of Electroencephalogram (EEG)Coverage and medical review for CPT 95957 when substantial additional digital EEG analysis is medically necessary to evaluate possible epileptic spikes or seizures or support presurgical evaluation of intractable epilepsy.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyElidel and Protopic Coverage CriteriaCoverage and prior authorization requirements for Elidel (pimecrolimus) and Protopic (tacrolimus) for short-term and intermittent treatment of mild to moderate atopic dermatitis.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyForteo (teriparatide) Coverage CriteriaThis policy governs SoonerCare prior authorization and coverage of Forteo (teriparatide) for osteoporosis, including initial and continuation therapy requirements, safety restrictions, approval duration, and total lifetime coverage limits.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyGlumetza and Fortamet Extended-Release Metformin Coverage CriteriaThis policy governs prior authorization for Glumetza and Fortamet. Approval requires documentation that the member cannot take generic metformin extended-release formulations after slow titration.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyHome Parenteral NutritionThis guideline governs prior authorization and medical-necessity requirements for adult and pediatric home parenteral nutrition, including PN solutions, additives, supplies, and infusion pumps.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyImmune Globulin (IG) Intravenous (IV) and Subcutaneous (SC) Coverage CriteriaThis policy governs Oklahoma Health Care Authority prior authorization requirements for specified intravenous and subcutaneous immune globulin products for SoonerCare members.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyImmunomodulators: Elidel / Protopic Coverage CriteriaThis policy governs Oklahoma SoonerCare coverage and prior authorization for Elidel (pimecrolimus) and Protopic (tacrolimus) topical immunomodulators, including age requirements, corticosteroid trial requirements, quantity limits, utilization frequency, approved indications, and immunocompromised-member restrictions.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyInhaled Tobramycin and Pulmozyme Coverage CriteriaThis policy governs SoonerCare coverage and pharmacy claims processing for inhaled tobramycin products and Pulmozyme (dornase alfa) for members with cystic fibrosis.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyLamisil Granules Prior AuthorizationThis policy governs Oklahoma Medicaid prior authorization for Lamisil granules, primarily for members with tinea capitis. It establishes clinical criteria for approval and summarizes fiscal year 2011 utilization, petition activity, and safety-labeling updates.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyLong-term Electroencephalographic (EEG) MonitoringThis guideline governs medical necessity and prior authorization for long-term continuous EEG and video-EEG monitoring, including technical and professional components. It applies to providers requesting or documenting these services for OHCA members.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyMuscle Relaxant Prior Authorization CriteriaThis policy governs Oklahoma Health Care Authority prior authorization and tiered coverage criteria for skeletal muscle relaxants, including Tier-2 products, carisoprodol, tizanidine capsules, and extended-release cyclobenzaprine products.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyOffice-Based Targeted Excimer Laser TherapyThis guideline governs medical necessity, prior authorization, documentation, coding, treatment limits, and continued coverage for office-based targeted excimer laser therapy for localized psoriasis and vitiligo.All Oklahoma Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyPaid Family Caregiver (PFC) ServicesGuidelines for Oklahoma SoonerCare and SoonerSelect coverage, authorization, provider qualifications, caregiver requirements, billing, and service limits for Paid Family Caregiver services for children ages 0 through 20 approved for private duty nursing.All Oklahoma Health Care Authority updates
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Tool Description
Search Oklahoma Health Care Authority 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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