Pennsylvania Insurance Department Coverage Criteria
- Pennsylvania Insurance Department prior authorization
- All Pennsylvania Insurance Department policy updates
Latest Pennsylvania Insurance Department coverage criteria updates8
- Coverage CriteriaClinical/Medical PolicyEff. 2024-01-08Prior Authorization of Pituitary Suppressive Agents, LHRH - Pharmacy ServicesDefines prior authorization requirements and medical necessity criteria for pituitary suppressive agents (LHRH) for all licensed pharmacies and prescribers enrolled in Pennsylvania Medical Assistance, including FFS and MA MCOs.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Prior Authorization of Anti-Allergens, Oral - Pharmacy ServicesGoverns prior authorization requirements and medical necessity criteria for oral anti-allergen prescriptions for providers and pharmacies participating in Pennsylvania Medical Assistance fee-for-service.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-01-28Prior Authorization of Alpha-1 Proteinase InhibitorsGoverns prior authorization requirements and medical necessity criteria for prescriptions of Alpha-1 Proteinase Inhibitors for Medical Assistance (fee-for-service) providers and pharmacies in Pennsylvania's MA program.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-06-13Prior Authorization of Provenge (sipuleucel-T) - Pharmacy ServiceRequires prior authorization for all Provenge (sipuleucel-T) prescriptions under Pennsylvania Medical Assistance fee-for-service and describes the clinical documentation and dose/duration limits used to determine medical necessity for covered recipients.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyAct 62: Autism Insurance Act Fact Sheet — Coverage CriteriaOverview of Pennsylvania's Act 62 requiring many private group health plans, Medical Assistance, and CHIP to cover diagnostic assessment and treatment services for autism spectrum disorder for individuals under age 21, and outlining who and what is covered and treatment requirements.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyAdult Day Services — Coverage CriteriaDefines services, eligibility concepts, and service specifications for adult day services and related home- and community-based supports provided through Pennsylvania Area Agencies on Aging (AAAs). Affects providers, AAAs, and enrolled consumers receiving OPTIONS/Adult Day-related services.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyEmergency Department Opioid Use Disorder (OUD) Program — Coverage CriteriaGuidance and Q&A on DHS's ED-focused OUD program covering definitions of denominator/numerator, required pathways (including pregnant patients), data/reporting (claims, CCD/ADT submission), attendance/staffing and attestation requirements for hospitals participating in Pennsylvania's HealthChoices program.All Pennsylvania Insurance Department updates
- Coverage CriteriaClinical/Medical PolicyPrior authorization criteria for Korlym (mifepristone)Governs prior authorization requirements and medical necessity criteria for Korlym (mifepristone) prescriptions for Medical Assistance recipients; applies to prescribers and prior authorization reviewers within the Pennsylvania Insurance Department program.All Pennsylvania Insurance Department updates
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Tool Description
Search Pennsylvania Insurance Department 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
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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.
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