UCare Coverage Criteria
Latest UCare coverage criteria updates15
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Reconstructive and Cosmetic Health ServicesDefines medical necessity criteria, examples of reconstructive services that are covered, and examples of cosmetic services that are not medically necessary for UCare members; applies to providers submitting coverage requests and prior authorizations in Minnesota and other UCare plans as described.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-03-15Adzynma (recombinant ADAMTS13) — coverage criteria for congenital TTPDefines prior authorization, coverage criteria, dosing, and documentation requirements for Adzynma (recombinant ADAMTS13) used as prophylactic or on‑demand enzyme replacement in congenital thrombotic thrombocytopenic purpura for adult and pediatric patients.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-15Adstiladrin (nadofaragene firadenovec) — Utilization Management / Coverage CriteriaDefines utilization management, prior authorization, and coverage criteria for Adstiladrin for adults with high‑risk BCG‑unresponsive non‑muscle invasive bladder cancer (CIS with or without papillary tumors or Ta/T1 papillary tumors without CIS) across all UCare plans.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-11-15Oncology (Intravesical) - Adstiladrin UM Medical PolicyDefines prior authorization and medical necessity criteria for coverage of Adstiladrin in adults with BCG-unresponsive non-muscle invasive bladder cancer (NMIBC); applies to all UCare plans.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-01-01Oncology (Injectable - Microtubule Inhibitor) - Paclitaxel Albumin-Bound Products Utilization Management Medical PolicyDefines prior authorization, coverage criteria, and dosing for paclitaxel albumin-bound (Abraxane) for UCare Medical Assistance and Exchange plans; applies to oncologists and providers prescribing this agent for adult cancer indications.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2021-07-01Abecma (idecabtagene vicleucel) — Medical-benefit prior authorization and coverage criteriaDefines medical-benefit prior authorization and coverage criteria for Abecma (idecabtagene vicleucel) for UCare Medical Assistance and Exchange Plans, applicable to adults with relapsed or refractory multiple myeloma after prior therapies.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-05-01Sickle Cell Disease - Adakveo Utilization Management Medical PolicyThis policy governs prior authorization and medical benefit coverage criteria for Adakveo (crizanlizumab-tmca) to reduce vasoocclusive crises in patients with sickle cell disease age ≥16 across all UCare plans.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Adcetris (brentuximab) utilization and coverage criteriaDefines prior authorization, coverage criteria, dosing limits, and approved indications for Adcetris (brentuximab) for UCare plans; applies to providers prescribing or administering the drug.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Enzyme Replacement Therapy - Aldurazyme (laronidase) Utilization Management Medical PolicyDefines prior authorization and coverage criteria for Aldurazyme (laronidase IV) for treatment of mucopolysaccharidosis type I (MPS I) across all UCare plans, including diagnostic requirements, prescriber specialty, dosing limits, and approval duration.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Inflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical PolicyThis policy governs prior authorization and coverage criteria for intravenous tocilizumab products (Actemra, Avtozma, Tofidence) for UCare Medical Assistance and Exchange Plans. It outlines indications, dosing, step therapy (preferred product Tyenne), and authorization durations for approved indications.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Inflammatory Conditions - Tocilizumab Intravenous Products Utilization Management Medical PolicyDefines prior authorization, step-therapy, and medical necessity criteria for intravenous tocilizumab products (Actemra, Avtozma, Tofidence) for UCare medical plans; excludes acute inpatient COVID-19 treatment. Affects prescribers, prior auth reviewers, and plan members.All UCare updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Repository Corticotropin (Acthar Gel) Utilization ManagementDefines prior authorization, coverage criteria, dosing, and conditions for approval or non-coverage of Acthar Gel for UCare members; applies to prescribers requesting pharmacy benefit coverage of repository corticotropin (Acthar Gel).All UCare updates
- Coverage CriteriaClinical/Medical PolicyHome health and home infusion pre-certification/authorization form coverage criteriaThis document governs pre-certification and authorization requests for home health, home infusion, MDO, or AIC services submitted to CARECONTINUUM on behalf of UCare members; it affects ordering prescribers, billing providers, and suppliers seeking coverage. It specifies the information providers must supply for review and may require prescriber review for certain requests.All UCare updates
- Coverage CriteriaClinical/Medical PolicyMedical Injectable Drug Authorization List (coverage criteria)List of medical injectable drugs typically administered in provider offices that require prior authorization or step therapy under UCare's medical benefit; applies to participating and non-participating providers submitting authorization requests.All UCare updates
- Coverage CriteriaClinical/Medical PolicyMedical Injectable Drug Authorization List (coverage criteria)All UCare updates
1–15 of 15
1 / 1
Tool Description
Search UCare 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
Go deeper
Explore OpenPayer Data
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.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Prior Authorization LookupSearch payer prior authorization policies by drug, procedure, or policy name.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.