Peach State Health Plan Coverage Criteria
- Peach State Health Plan prior authorization
- Peach State Health Plan timely filing
- All Peach State Health Plan policy updates
Latest Peach State Health Plan coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Keratoplasty (corneal transplant)Medical necessity criteria and coding guidance for corneal transplant procedures (keratoplasty) for members of Peach State Health Plan/affiliated Centene health plans. Applies to providers requesting coverage for corneal transplant procedures.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-25Infusion Therapy Site of Care OptimizationDefines medical necessity criteria and approval requirements for outpatient intravenous or injectable specialty infusion therapy and guidance for redirecting site of care among hospital outpatient, ambulatory infusion centers, offices, pharmacies, and home settings for Peach State Health Plan members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-26Peginterferon alfa-2a (Pegasys) Coverage CriteriaDefines medical necessity, coverage criteria, and authorization rules for peginterferon alfa-2a (Pegasys) across commercial, HIM/ICHRA, and Medicaid lines of business for Peach State Health Plan.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-16Clinical Policy: Abatacept (Orencia) Coverage CriteriaDefines medical necessity, exclusions, dosing, and therapeutic alternatives for abatacept (Orencia) for Peach State Health Plan members across indicated conditions and provides appendices with scoring systems and dose rounding guidance.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-24Dupilumab (Dupixent)Defines medical necessity criteria, dosing limits, prescriber qualifications, and approval durations for Dupilumab (Dupixent) across FDA‑approved and selected off‑label indications for Peach State Health Plan Medicaid members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-20Elbasvir/Grazoprevir (Zepatier) — Coverage CriteriaDefines medical necessity criteria, prior authorization requirements, and dosing/administration guidance for Zepatier (elbasvir/grazoprevir) for members covered under Peach State Health Plan (Medicaid). Applies to providers requesting coverage for Zepatier.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-20Ledipasvir/Sofosbuvir (Harvoni) — Coverage CriteriaDefines medical necessity, prior authorization requirements, and approval criteria for Harvoni for Peach State Health Plan Medicaid members, including age, genotype, cirrhosis, and alternative-preferred therapy requirements.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-03-16Topical Tretinoin in Adult Acne VulgarisThis policy defines medical necessity criteria, approval durations, and prescribing requirements for topical tretinoin when used to treat adult acne vulgaris for members covered by Peach State Health Plan.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01Casimersen (Amondys 45) coverageMedical necessity and prior authorization criteria for use of casimersen (Amondys 45) for Duchenne muscular dystrophy in Peach State Health Plan Medicaid members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-12-16Nadofaragene firadenovec-vncg (Adstiladrin) coverageDefines medical necessity criteria, dosing, and authorization requirements for Adstiladrin for treatment of high-risk BCG-unresponsive non-muscle invasive bladder cancer in adult members of Peach State Health Plan.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-10-01Elexacaftor/Ivacaftor/Tezacaftor; Ivacaftor (Trikafta) Coverage CriteriaDefines medical necessity and prior authorization criteria for Trikafta for Peach State Health Plan Medicaid members with cystic fibrosis, including initial and continued therapy requirements, dosing limits, and documentation expectations.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-06-01Ubrogepant (Ubrelvy) — Coverage Criteria for Acute MigraineDefines medical necessity and prior-authorization criteria for ubrogepant (Ubrelvy) for the acute treatment of migraine in adults under Peach State Health Plan (Medicaid). Applies to providers requesting coverage through the Centene-affiliated benefit.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-03-01Avapritinib (Ayvakit) coverageDefines medical necessity, prior authorization, and coverage criteria for avapritinib (Ayvakit) for commercial, HIM, and Medicaid lines of business at Peach State Health Plan.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-09-19Dipeptidyl Peptidase-4 (DPP-4) InhibitorsDefines prior authorization, coverage criteria, and limitations for dipeptidyl peptidase-4 (DPP-4) inhibitor products for Peach State Health Plan Medicaid members (adult type 2 diabetes mellitus).All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-09-19Glucagon-Like Peptide-1 (GLP-1) Receptor AgonistsDefines medical necessity, prior authorization, and coverage criteria for GLP-1 receptor agonist agents for Peach State Health Plan Medicaid members, including initial and continuation therapy rules and limitations of use.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-09-01Corticosteroids for Ophthalmic Injection (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq)Defines prior authorization, medical necessity, and coverage criteria for ophthalmic corticosteroid products (Dextenza, Iluvien, Ozurdex, Retisert, Xipere, Yutiq) for Peach State Health Plan members across Commercial, HIM/ICHRA, and Medicaid lines of business.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-03-13Age Limit Override (Codeine, Tramadol, Hydrocodone)Defines prior authorization requirements and clinical criteria for use of codeine-, tramadol-, and hydrocodone-containing medications in pediatric and other patients where FDA labeling imposes age limits; applies to Peach State Health Plan lines of business listed in the policy.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2017-02-01Brentuximab Vedotin (Adcetris)Defines medical necessity criteria, dosing limits, prescriber requirements, and approval durations for brentuximab vedotin (Adcetris) across multiple lymphoma indications for Peach State Health Plan members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2017-02-01Rolapitant (Varubi) coverageDefines medical necessity, prior authorization, and coverage criteria for rolapitant (Varubi) for prevention of chemotherapy-induced nausea and vomiting for applicable Peach State Health Plan lines of business.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-10-01Histrelin acetate (Vantas, Supprelin LA) coverageDefines medical necessity, prior authorization, and coverage criteria for Vantas and Supprelin LA for Peach State Health Plan members across Commercial, Medicaid, and HIM/ICHRA lines of business.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-09-16Clinical Policy: Sofosbuvir (Sovaldi)Defines medical necessity, prior authorization, and coverage criteria for sofosbuvir (Sovaldi) for treatment of hepatitis C virus (HCV) for Peach State Health Plan Medicaid members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-09-01Clinical Policy: Ixekizumab (Taltz)Defines medical necessity criteria, prescriber requirements, dosing limits, and continuation rules for coverage of ixekizumab (Taltz) for Peach State Health Plan (Medicaid) members.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-05-01Factor VIIa, Recombinant (NovoSeven RT, SevenFact)Defines medical necessity criteria, dosing limits, and authorization requirements for recombinant factor VIIa products (NovoSeven RT and SevenFact) for treatment of bleeding disorders across Peach State Health Plan lines of business.All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-03-01C1 Esterase Inhibitors (Berinert, Cinryze, Haegarda, Ruconest)Prior authorization and medical necessity criteria for C1 esterase inhibitor products for the treatment and prophylaxis of hereditary angioedema (HAE) for Peach State Health Plan members (Commercial and Medicaid).All Peach State Health Plan updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-02-01Vigabatrin (Sabril, Vigafyde) coverageDefines medical necessity criteria, prior authorization, and coverage conditions for vigabatrin products (Sabril, Vigafyde) across Peach State Health Plan lines of business including Commercial, ICHRA, and Medicaid.All Peach State Health Plan updates
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Tool Description
Search Peach State Health Plan 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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