Sierra Health And Life Coverage Criteria
Latest Sierra Health And Life coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment DecisionsPolicy governing coverage of molecular oncology testing for diagnosis, prognosis, and treatment decisions for solid tumor cancers under Sierra Health and Life (UnitedHealthcare) Commercial and Individual Exchange benefit plans. Applies to tests that are not FDA-cleared/approved companion diagnostics.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Adakveo (crizanlizumab-tmca) – Medical Benefit Coverage CriteriaClinical policy governing medical-benefit coverage of Adakveo (crizanlizumab-tmca) for members with sickle cell disease under UnitedHealthcare Commercial and Individual Exchange plans. It defines initial and continuation therapy criteria, exclusions, and applicable codes for providers and prior authorization processes.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Advantage 4-Tier Prescription Drug List (PDL) - Coverage CriteriaA formulary (PDL) describing covered prescription medications, tiering, and coverage controls for Sierra Health and Life medical plan members whose pharmacy benefit uses the Advantage 4-Tier PDL.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Amondys 45 (casimersen) — coverage criteria for Duchenne muscular dystrophyDefines coverage criteria and requirements for Amondys 45 (casimersen) for treatment of Duchenne muscular dystrophy in members covered under UnitedHealthcare Commercial and Individual Exchange benefit plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Crysvita (burosumab-twza) — Coverage Criteria for X-linked hypophosphatemia (XLH) and FGF23-related hypophosphatemia in TIOThis policy governs medical necessity criteria, prior authorization, and coding for Crysvita (burosumab-twza) for treatment of X-linked hypophosphatemia (XLH) and FGF23-related hypophosphatemia in tumor-induced osteomalacia (TIO) for applicable UnitedHealthcare commercial and individual exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Edaravone (Radicava) for amyotrophic lateral sclerosis (ALS)This policy governs medical benefit coverage criteria for intravenous edaravone (Radicava) for treatment of amyotrophic lateral sclerosis and applies to UnitedHealthcare commercial members under Sierra Health and Life in North Carolina.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Enteral Nutrition (Oral and Tube Feeding)UnitedHealthcare Commercial and Individual Exchange medical policy addressing medical necessity, coverage limitations, definitions, and applicable codes for enteral nutrition (oral and tube feeding) including Specialized Nutrient Formulas/Medical Foods; applies to UnitedHealthcare Commercial plans and Individual Exchange plans (all states except Wisconsin). This brief covers Part 1 of the policy document.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Essential 4-Tier Prescription Drug List (PDL) — Pharmacy Coverage CriteriaPDL governing pharmacy benefit coverage tiers, prior authorization, and coverage notes for Sierra Health and Life medical plan members enrolled in the Essential 4-Tier PDL; applies to medications and informs members and providers about formulary status and coverage requirements.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Exondys 51 (eteplirsen) — Medical Benefit Drug Policy (coverage criteria)Medical benefit drug policy describing coverage criteria, clinical evidence, and coding for Exondys 51 (eteplirsen) for treatment of Duchenne muscular dystrophy; applies to UnitedHealthcare Commercial and Individual Exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Facet Joint and Medial Branch Block Injections for Spinal PainDefines medical necessity, investigational/unproven indications, coding references, and clinical evidence for diagnostic and therapeutic facet joint and medial branch block injections for members under UnitedHealthcare Commercial and Individual Exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Hyperbaric Oxygen Therapy and Topical Oxygen TherapyDefines medical necessity and investigational status for hyperbaric oxygen therapy (HBOT), mild HBOT, and topical oxygen therapy for UnitedHealthcare Commercial and Individual Exchange plans; applies to providers treating wounds and related conditions.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Implantable Recorders Wearable MonitorsDefines medical necessity criteria for implantable loop recorders (ILRs) and coverage stance for wearable cardiac self-monitoring devices for UnitedHealthcare Commercial and Individual Exchange plans; excludes individuals <18 years. Also addresses replacement of ILRs and describes devices considered convenience items (consumer-grade/self-monitoring).All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Itvisma (Onasemnogene Abeparvovec-Brve) — Medical Benefit Drug Policy (Intrathecal gene therapy for SMA)Defines medical benefit coverage criteria for a single-dose intrathecal Itvisma for treatment of spinal muscular atrophy (SMA) in patients aged ≥2 years with qualifying SMN1/SMN2 genetics and other clinical requirements, for UnitedHealthcare Commercial and Individual Exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Ketalar (Ketamine) and Spravato (Esketamine) — Coverage CriteriaDefines medical necessity, coverage criteria, and investigational exclusions for Spravato (esketamine) nasal spray and ketamine injections for UnitedHealthcare Commercial and Individual Exchange plans; affects providers prescribing or administering these agents for depression, suicidal ideation, anesthesia, and pain.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Lower Extremity Endovascular Procedures — Coverage CriteriaClinical coverage criteria for endovascular revascularization (stents, angioplasty, atherectomy, intravascular lithotripsy, etc.) for lower extremity peripheral artery disease for UnitedHealthcare Commercial and Individual Exchange members; excludes upper extremities.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Molecular Oncology Testing for Solid Tumor Cancer Diagnosis, Prognosis, and Treatment DecisionsDefines medical necessity and coverage criteria for molecular and gene expression testing for solid tumor cancers (tissue and liquid biopsy) for UnitedHealthcare Commercial and Individual Exchange plans. Affects ordering clinicians, laboratories, and members under those plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Orthognathic (Jaw) Surgery — Coverage CriteriaDefines clinical coverage criteria and coding references for reconstructive orthognathic (jaw) surgery for UnitedHealthcare Commercial and Individual Exchange benefit plans; applies to members with facial skeletal deformities and associated functional impairment.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Qalsody (tofersen) — Coverage Criteria for SOD1‑mutation ALSMedical benefit drug policy governing coverage criteria for Qalsody (tofersen) to treat adults with amyotrophic lateral sclerosis (ALS) who have a SOD1 gene mutation; applies to UnitedHealthcare Commercial and Individual Exchange plans (as adopted by Sierra Health and Life).All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Veopoz (pozelimab‑bbfg) — Medical Benefit Coverage Criteria for CD55‑deficient PLE (CHAPLE)This policy governs medical benefit coverage and prior authorization criteria for Veopoz (pozelimab‑bbfg) for members on UnitedHealthcare Commercial and Individual Exchange plans for treatment of CD55‑deficient protein‑losing enteropathy (PLE/CHAPLE). It applies to providers seeking coverage under those plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Viltolarsen (Viltepso) for Duchenne muscular dystrophyPolicy governing medical benefit coverage criteria for viltolarsen (Viltepso) to treat Duchenne muscular dystrophy (DMD) in patients with DMD gene mutations amenable to exon 53 skipping; applies to the payer's commercial and individual exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-01Vyondys 53 (golodirsen) — coverage criteria for Duchenne muscular dystrophy (exon 53 skipping)Defines medical necessity criteria, coding, and coverage stance for Vyondys 53 (golodirsen) for treatment of Duchenne muscular dystrophy in members whose DMD gene mutation is amenable to exon 53 skipping; applies to UnitedHealthcare Commercial and Individual Exchange plans noted in the document.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Cardiovascular Disease Risk Tests (Coverage Criteria)Defines UnitedHealthcare policy stance on a range of cardiovascular risk tests (arterial compliance/waveform analysis, carotid intima-media thickness, advanced lipoprotein and multiprotein biomarker assays, Lp-PLA2) for Commercial and Individual Exchange plans.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Complement C5 InhibitorsCoverage and medical necessity criteria for complement C5 inhibitor drugs (Bkemv, Epysqli, PiaSky, Soliris, Ultomiris) for Sierra Health and Life members under the medical benefit; includes diagnosis-specific criteria and preferred product rules.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Denosumab (Prolia, biosimilars) medical benefit drug policy — non-oncology coverage criteriaDefines medical necessity, preferred product rules, diagnosis-specific coverage criteria, and applicable billing codes for denosumab products for non-oncology indications for UnitedHealthcare Commercial members (Sierra Health and Life). Affects providers requesting authorization for denosumab formulations including branded and biosimilar products.All sierra health and life updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Enjaymo (sutimlimab-jome) — Coverage Criteria for Cold Agglutinin DiseaseMedical policy governing coverage criteria and administrative requirements for Enjaymo (sutimlimab-jome) for treatment of cold agglutinin disease (CAD) under Sierra Health and Life (UnitedHealthcare) Commercial and Individual Exchange benefit plans.All sierra health and life updates
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Search Sierra Health And Life 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.
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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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