SelectHealth Coverage Criteria
Latest SelectHealth coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Prescription drug list (formulary) - Coverage CriteriaSummarizes commonly prescribed drugs covered by SelectHealth plans, explains tiers, cost-sharing, and administrative controls (e.g., prior authorization, step therapy, quantity limits) for members and providers.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Prescription drug list (formulary) - Coverage CriteriaThis document is a summary of commonly prescribed drugs covered by SelectHealth plans (the formulary), including tier placement, special requirements (e.g., preauthorization, step therapy, quantity limits, age limits), and guidance for members and providers on coverage and costs.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Prescription drug list (formulary) — Coverage CriteriaThis document summarizes commonly prescribed drugs covered by SelectHealth plans, including tier placement, requirements (e.g., prior authorization, step therapy, quantity limits, age limits), and instructions for members and providers on coverage and exceptions.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-01-01Prescription drug list (formulary) — Coverage criteriaSummary of commonly prescribed drugs covered by SelectHealth plans, tiering, coverage limits, and requirements (e.g., preauthorization, step therapy, quantity limits) for members and providers.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Prescription drug formulary — Coverage criteria and utilization controlsSummary of commonly prescribed drugs covered by SelectHealth plans, describing formulary structure, cost tiers, and coverage rules that affect members, providers, and pharmacies.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-10-01Prescription drug list (formulary) — coverage criteriaThis document summarizes commonly prescribed drugs that SelectHealth covers, explains tiers, cost-sharing, and special requirements (preauthorization, step therapy, quantity limits, age limits) and directs members to the full online formulary and pharmacy services for details.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-12-21Compounded MedicationsCoverage criteria for compounded medications across SelectHealth Commercial, Medicare (CMS), and Community Care (Medicaid); specifies when compounded prescriptions are medically necessary and includes billing/coding and prior authorization guidance.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-14Autologous Serum Eye Drops (Ophthalmology/Optometry Coverage Criteria)This policy defines SelectHealth's coverage stance for autologous serum eye drops for dry eye and related ocular surface disorders across Commercial, Medicare, and Medicaid lines of business.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-30SelectHealth Clinical/Medical Policy — General Surgery: Coverage CriteriaSelectHealth clinical/medical policy brief listing General Surgery policies and coverage criteria applicable to SelectHealth Commercial, Medicare, and Medicaid plans; guides provider coverage requests.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-30Varicose Vein Procedures (General Surgery) — Coverage CriteriaThis document governs SelectHealth's coverage determinations for varicose vein procedures (Policy #193) as part of the General Surgery medical policies; it affects providers treating SelectHealth Commercial, Medicare, and Community Care (Medicaid) members. (Note: this output is based on the first part of the policy document provided.)All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-26Optilume urethral drug-coated balloon (DCB) — Coverage CriteriaSelectHealth coverage policy for the Optilume urethral drug-coated balloon for treatment of urethral strictures, including coverage criteria, exclusions, contraindications, and applicable CPT codes; applies to SelectHealth Commercial, Medicare (when CMS has no determination), and SelectHealth Community Care (Medicaid) where noted.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-26Optilume urethral drug‑coated balloon (DCB) for urethral stricture — Coverage CriteriaCoverage criteria for Optilume urethral drug‑coated balloon for treatment of recurrent bulbar urethral strictures in SelectHealth members; includes related coverage positions for PTNS, pelvic vein procedures, penile implants, TLV, and other urologic interventions across Commercial, Medicare (CMS), and Community Care (Medicaid) products.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-09-01Coverage with Evidence DevelopmentDefines SelectHealth's approach to covering items/services conditionally when evidence is being developed, aligning with CMS CED paradigms and applying to Commercial, Medicare, and Medicaid/CHIP plans as specified.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-08-16Bronchial Thermoplasty for AsthmaDefines SelectHealth coverage criteria and coding guidance for bronchial thermoplasty (BT) for treatment of severe persistent asthma for commercial, Medicare, and Medicaid lines where applicable.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-08-16Bronchial Thermoplasty for AsthmaCoverage and medical necessity criteria for bronchial thermoplasty (BT) for treatment of severe persistent asthma for SelectHealth commercial, Medicare (when CMS has no determination), and SelectHealth Community Care (Medicaid) members.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-08-16Bronchial thermoplasty for asthmaCoverage criteria and clinical background for bronchial thermoplasty (BT) in SelectHealth commercial, Medicare (when CMS has no criteria), and Community Care (Medicaid) plans; outlines when BT is covered vs investigational.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-08-01Vagus Nerve Stimulation (VNS) — Neurology/Neurosurgery Coverage CriteriaThis SelectHealth policy governs coverage and clinical criteria for VNS devices and related neuromodulation procedures across Commercial, Medicare (CMS), and Community Care plans, including documentation, prior authorization, and exclusions described for multiple neurostimulation indications.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Withdrawal ManagementDefines SelectHealth coverage criteria, clinical requirements, and billing guidance for ABA therapy for individuals with Autism Spectrum Disorder across commercial, Medicare, and Medicaid products (state-specific rules may apply). Affects providers requesting authorization and delivering ABA services.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-28Acute Inpatient RehabilitationThis policy governs coverage criteria and requirements for acute inpatient rehabilitation (IRF) services for SelectHealth members (Commercial, Medicare, and Community Care/CHIP), detailing qualifying conditions, admission criteria, and program expectations for adult and pediatric patients.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-06-28Acute Inpatient Rehabilitation (IRF) coverageSelectHealth policy describing coverage criteria, requirements, and applicable conditions for acute inpatient rehabilitation (IRF) admissions for commercial, Medicare (when CMS criteria absent), and Select Health Community Care plans. Affects providers requesting or delivering inpatient rehabilitation services.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-02-15Chelation TherapyThis policy describes Select Health coverage determinations for chelation therapy (intravenous or oral chelating agents) for treatment of metal toxicity and specified indicated conditions across Commercial, Medicare, and Medicaid lines of business.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-02-07Cone-Beam Computed Tomography (CBCT) for Dental Conditions Under the Medical BenefitSelectHealth policy governing coverage of CBCT imaging for dental, oral and maxillofacial conditions under the medical benefit across plan types (Commercial, Medicare, Medicaid/Community Care). It states coverage determinations and rationale for when CBCT is considered medically necessary or not.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-02-07Cone-Beam Computed Tomography (CBCT) for Dental/Oral-Maxillofacial ConditionsGoverns CBCT coverage determinations for dental/oral-maxillofacial conditions under SelectHealth medical benefits, states commercial noncoverage for dental CBCT, and references Medicare/Medicaid alignment; affects providers submitting CBCT claims.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-29Fecal Microbiota Therapy (FMT) Coverage CriteriaThis policy governs coverage determinations for fecal microbiota therapy (including fresh stool and commercially prepared frozen capsules) for SelectHealth members with Clostridioides difficile infection and specifies clinical criteria and applicable delivery methods.All SelectHealth updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-01-01SelectHealth coverage policies for compounded medications; diagnostic testing for CFS; estradiol pellets; IV antibiotics for Lyme disease; viscosupplementationContains SelectHealth coverage criteria, exclusions, plan-specific guidance (Commercial, Medicare/CMS, Community Care/Medicaid), coding references, and clinical rationale for compounded medications, CFS diagnostic testing, estradiol pellets, IV antibiotics for Lyme disease, and viscosupplementation.All SelectHealth updates
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Tool Description
Search SelectHealth 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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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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