Viva Health Coverage Criteria
Latest Viva Health coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Botox (onabotulinumtoxinA) — Coverage CriteriaDefines Viva Health prior-authorization, dosing limits, and medical necessity criteria for onabotulinumtoxinA (Botox) for multiple indications across intramuscular, intradetrusor, and intradermal uses; applies to providers requesting coverage for members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Cinqair (reslizumab) IV — coverage and prior authorization criteriaClinical coverage and prior authorization criteria for intravenous reslizumab (Cinqair) for members of Viva Health, including initial and renewal requirements, dosing limits, contraindicated concomitant therapies, and billing information.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Decnupaz (pivekimab sunirine-pvzy) prior authorization and coverageDefines prior authorization, dosing limits, clinical criteria, coding, and renewal rules for intravenous Decnupaz (pivekimab sunirine-pvzy) for adults with CD123‑expressing Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN). Applies to Viva Health benefit administration.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Dysport® (abobotulinumtoxinA) — Coverage CriteriaDefines prior authorization, dosing limits, indications, and renewal criteria for Dysport (abobotulinumtoxinA) for Viva Health members receiving intramuscular, intradetrusor, or intradermal injections.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Evenity (romosozumab-aqqg) (Subcutaneous) — Coverage CriteriaDefines prior authorization, dosing limits, eligibility, and billing/coding for Evenity (romosozumab-aqqg) for treatment of osteoporosis, primarily in postmenopausal women, for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Firmagon (degarelix) coverage and prior authorizationPolicy governing prior authorization, dosing, and coverage criteria for Firmagon (degarelix) for treatment of prostate cancer for Viva Health members age 18 and older.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Krystexxa (pegloticase) — Prior Authorization and Coverage CriteriaDefines prior authorization, dosing limits, initial and renewal medical necessity criteria, and billing/coding for intravenous Krystexxa (pegloticase) for members eligible under Viva Health.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Leuprolide Suspension (coverage criteria)Defines Viva Health prior authorization, dosing limits, and medical necessity criteria for leuprolide suspension formulations across multiple indications including CPP, cancer, endometriosis, fibroids, gender dysphoria, fertility preservation, and HCT-related bleeding.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Levoleucovorin (Fusilev; Khapzory) — Intravenous Coverage CriteriaDefines prior authorization, dosing limits, indications, and renewal criteria for intravenous levoleucovorin (Fusilev and Khapzory) for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Nucala (mepolizumab) prior authorization and coverage criteriaThis policy describes prior authorization, dosing limits, initial and renewal clinical criteria, and concomitant therapy restrictions for coverage of subcutaneous mepolizumab (Nucala) for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Qalsody (tofersen) (Intrathecal) — Coverage CriteriaDefines prior authorization, dosing, eligibility, renewal, billing codes, and documentation requirements for intrathecal Qalsody (tofersen) in members with SOD1-mutant ALS under Viva Health.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Radicava (edaravone) — IntravenousThis policy governs prior authorization, dosing limits, clinical criteria, and billing for intravenous edaravone (Radicava) for treatment of amyotrophic lateral sclerosis (ALS) for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Rituximab (Riabni, Rituxan, Ruxience, Truxima) Coverage CriteriaDefines prior authorization, length of authorization, dosing limits, and renewal rules for rituximab (Riabni, Rituxan, Ruxience, Truxima) for oncology and non-oncology indications for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Sustol (granisetron extended-release) — Coverage CriteriaCovers prior authorization, dosing, clinical criteria, and billing for Sustol (granisetron extended-release) when used for prevention of chemotherapy-induced nausea and vomiting (CINV) in Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Tecentriq (atezolizumab) — Coverage and Authorization PolicyDefines prior authorization, dosing limits, length of authorization, and clinical coverage criteria for intravenous atezolizumab (Tecentriq) for Viva Health members across multiple cancer indications.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-07-01Triptodur® (triptorelin) (Intramuscular) — Coverage CriteriaDefines Viva Health prior authorization, dosing, indications, renewal, billing codes, and clinical criteria for Triptodur® (triptorelin) intramuscular 6-month formulation for members, including pediatric central precocious puberty and gender dysphoria indications.All Viva Health updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-06-02Herceptin Hylecta (trastuzumab and hyaluronidase-oysk) — SubcutaneousThis Viva Health reimbursement policy governs prior authorization, dosing, coverage criteria, and billing information for Herceptin Hylecta (subcutaneous trastuzumab with hyaluronidase) for adults with HER2-positive breast cancer and affects Viva Health members and providers seeking coverage for this drug.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Kadcyla (ado-trastuzumab emtansine) — coverage criteriaDefines Viva Health prior authorization, dosing, approval and renewal criteria, and billing codes for Kadcyla (ado-trastuzumab emtansine) for oncology indications; applies to providers requesting coverage for members receiving this intravenous oncology drug.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Ocrevus (ocrelizumab) prior authorization and coverage for multiple sclerosisThis policy governs prior authorization, dosing limits, coverage criteria, renewal requirements, and billing/coding for ocrelizumab (Ocrevus) intravenous therapy for members receiving MS treatment under Viva Health.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Perjeta® (pertuzumab) (Intravenous) — Coverage CriteriaDefines prior authorization, dosing limits, indications, and renewal criteria for intravenous pertuzumab (Perjeta) for Viva Health members; applies to providers requesting coverage for this drug.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Spevigo (spesolimab) (Intravenous) — Coverage CriteriaDefines Viva Health prior authorization, dosing, and medical necessity criteria for intravenous Spevigo (spesolimab) for members, including initial authorization, dosing limits, and renewal restrictions.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-02Visudyne (verteporfin) (Intravenous) Coverage CriteriaCovers prior authorization, dosing, eligible indications, and billing for intravenous Visudyne (verteporfin) therapy for Viva Health members; applies to providers requesting coverage for Visudyne infusions.All Viva Health updates
- Coverage CriteriaReimbursement/Payment PolicyEff. 2026-06-02Wainua (eplontersen) — Coverage and Prior AuthorizationDefines Viva Health's coverage, prior authorization, dosing, and renewal criteria for Wainua (eplontersen) subcutaneous therapy for treatment of hATTR polyneuropathy for applicable members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-05Elzonris (tagraxofusp-erzs) — intravenous therapy for BPDCNPrior authorization and coverage criteria for intravenous tagraxofusp-erzs (Elzonris) for treatment of blastic plasmacytoid dendritic cell neoplasm (BPDCN) and related administration, dosing, and monitoring requirements for Viva Health members.All Viva Health updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-05-05Empliciti (elotuzumab) (Intravenous) — Prior Authorization Coverage CriteriaPrior authorization policy for Empliciti (elotuzumab) IV for treatment of multiple myeloma and related plasma cell disorders for Viva Health members; defines dosing limits, initial and renewal criteria, administration, and applicable diagnosis codes.All Viva Health updates
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Tool Description
Search Viva Health 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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