QualChoice Coverage Criteria
Latest QualChoice coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-09-01Linerixibat (Lynavoy) Coverage CriteriaPrior authorization and medical-necessity coverage for Lynavoy (linerixibat) to treat cholestatic pruritus associated with primary biliary cholangitis in adults across QualChoice commercial, marketplace/ICHRA, and Medicaid plans.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Clinical Policy: Tradipitant (Nereus)Defines medical necessity and prior authorization criteria for coverage of tradipitant (Nereus) for prevention of motion-induced vomiting in adults across QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Difamilast (Adquey) topical for atopic dermatitisDefines medical necessity, prior authorization, and coverage criteria for topical difamilast (Adquey) for members age 2 and older across QualChoice lines of business (Commercial, HIM/ICHRA, Medicaid). Affects providers requesting coverage or continuation of Adquey.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Insulin icodec-abae (Awiqli) coverage criteriaDefines medical necessity, prior authorization, and coverage criteria for Awiqli (insulin icodec-abae) for adults with type 2 diabetes mellitus under QualChoice HIM/ICHRA lines of business; applies to providers requesting coverage and prior authorization.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Sibeprenlimab-szsi (Voyxact) for IgA NephropathyPolicy governing prior authorization, medical necessity criteria, and coverage for Voyxact (sibeprenlimab-szsi) to reduce proteinuria in adults with primary IgA nephropathy for members of QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Clinical Policy: Depemokimab-ulaa (Exdensur)Defines medical necessity, prior authorization, and coverage criteria for Exdensur (depemokimab-ulaa) as add-on maintenance treatment of severe eosinophilic asthma for eligible members; applies to QualChoice HIM line of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Etripamil (Cardamyst) for PSVTDefines medical necessity and coverage criteria for Cardamyst (etripamil) nasal spray for conversion of acute symptomatic paroxysmal supraventricular tachycardia (PSVT) and related authorization rules for affected QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-03-01Ziftomenib (Komzifti) coverageDefines medical necessity and prior authorization criteria for ziftomenib (Komzifti) for treatment of adult patients with relapsed or refractory NPM1‑mutated acute myeloid leukemia across QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-27Navepegritide (Yuviwel) — Coverage Criteria for AchondroplasiaDefines medical necessity and prior authorization requirements for navepegritide (Yuviwel) for pediatric achondroplasia across applicable QualChoice lines of business (Commercial, ICHRA/HIM, Medicaid). Affects providers requesting coverage for initiation and continuation of therapy.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-23Pegzilarginase-nbln (Loargys) coverageDefines medical necessity criteria, authorization requirements, dosing, and coverage limits for Loargys (pegzilarginase-nbln) for treatment of arginase 1 deficiency in members of QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Urinary Incontinence Devices and TreatmentsDefines medical necessity criteria and coding guidance for sacral neuromodulation (SNS/SNM) and urethral bulking agents (UBA) for treating lower urinary tract dysfunction and stress urinary incontinence for QualChoice members/enrollees.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Semaglutide (Wegovy) coverageThis policy defines medical necessity criteria, authorization requirements, dosing limits, and duration for coverage of semaglutide (Wegovy) for specified QualChoice commercial lines of business and select groups; it applies only to members in specified benefit plan levels (BPLs) listed in the policy.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-24Narsoplimab‑wuug (Yartemlea) coverage for TA‑TMACriteria and authorization rules for coverage of Yartemlea (narsoplimab‑wuug) for treatment of hematopoietic stem cell transplant‑associated thrombotic microangiopathy (TA‑TMA) for qualifying members across listed lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Abrocitinib (Cibinqo) — Coverage Criteria for Atopic DermatitisDefines medical necessity criteria, dosing limits, and prior authorization requirements for abrocitinib (Cibinqo) for commercial and HIM lines of business for patients age ≥12 with moderate-to-severe atopic dermatitis.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-12-01Tralokinumab-ldrm (Adbry) for moderate-to-severe atopic dermatitisThis policy defines medical necessity criteria, dosing limits, and authorization requirements for Adbry (tralokinumab-ldrm) for members aged 12 years and older with moderate-to-severe atopic dermatitis, and specifies continuation, exclusions, and related formulary guidance for QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-18Plozasiran (Redemplo) — coverage criteria for familial chylomicronemia syndromeThis policy governs medical necessity criteria, prior authorization, and coverage for plozasiran (Redemplo) as adjunct to diet to reduce triglycerides in adults with familial chylomicronemia syndrome (FCS) for QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-11-03Doxecitine and Doxribtimine (Kygevvi) Coverage CriteriaDefines medical necessity and prior authorization criteria for Kygevvi for treatment of thymidine kinase 2 deficiency (TK2d) across applicable QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-19Elamipretide (Forzinity) coverage for Barth syndromeDefines medical necessity and prior authorization criteria for Forzinity (elamipretide) for members, primarily for treatment of Barth syndrome in eligible patients and guidance for other/off-label uses referencing related policies. Affects commercial, HIM, and Medicaid lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-09-12Cosmetic and Reconstructive ProceduresDefines medical necessity criteria, exclusions, and coding guidance for cosmetic and reconstructive surgical procedures for QualChoice members; affects providers submitting claims and requests for prior authorization.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-20Lebrikizumab-lbkz (Ebglyss) — Coverage Criteria for Atopic DermatitisCriteria and authorization rules for coverage of lebrikizumab-lbkz (Ebglyss) for treating moderate-to-severe atopic dermatitis in patients meeting age, weight, prior-therapy, and dosing requirements under QualChoice plans.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-14Zopapogene imadenovec-drba (Papzimeos) therapy for recurrent respiratory papillomatosisDefines medical necessity, prior authorization, and coverage criteria for Zopapogene imadenovec-drba (Papzimeos) for adults with recurrent respiratory papillomatosis (RRP) across QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-08-01Clinical Policy: Acquired Brain Injury (Subacute and Chronic) Inpatient NeurorehabilitationDefines medical necessity criteria, documentation, admission, continued stay, and discharge requirements for subacute and chronic inpatient neurorehabilitation for acquired brain injury across Arkansas Plans (QualChoice, Ambetter from Arkansas Health and Wellness, Arkansas Total Care, and QualChoice commercial plans).All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-03Sebetralstat (Ekterly) — Coverage CriteriaDefines medical necessity and prior authorization criteria for Ekterly (sebetralstat) when used to treat acute hereditary angioedema (HAE) in patients age 12 and older for QualChoice lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Atrasentan (Vanrafia) for IgA nephropathyDefines medical necessity criteria, prior authorization and continuation requirements for Vanrafia (atrasentan) primarily for adults with immunoglobulin A nephropathy (IgAN) with specified proteinuria and renal function, and applies to the payer's Commercial, HIM/ICHRA, and Medicaid lines of business.All QualChoice updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Datopotamab Deruxtecan-dlnk (Datroway)Policy governing medical necessity, prior authorization, and coverage criteria for datopotamab deruxtecan-dlnk (Datroway) across Commercial, HIM/ICHRA, and Medicaid lines of business for approved oncology indications.All QualChoice updates
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Tool Description
Search QualChoice 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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