Vivahealthplan Coverage Criteria
Latest Vivahealthplan coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyAdzynma coverage for congenital thrombotic thrombocytopenic purpuraThis policy governs prior authorization, dosing, renewal, billing, and coverage criteria for intravenous Adzynma (recombinant ADAMTS13) used to treat congenital thrombotic thrombocytopenic purpura, including prophylactic and on-demand therapy.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyAmvuttra (vutrisiran) Coverage CriteriaThis policy governs prior authorization, medical necessity, dosing, renewal, and billing requirements for subcutaneous Amvuttra (vutrisiran) for adult members with hereditary transthyretin-mediated amyloidosis polyneuropathy or wild-type/hereditary transthyretin amyloidosis cardiomyopathy.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyAvlayah (tividenofusp alfa-eknm) Coverage CriteriaThis policy governs prior authorization and medical necessity coverage for intravenous Avlayah (tividenofusp alfa-eknm) for members with Mucopolysaccharidosis type II (Hunter syndrome). It applies to providers seeking initial or continued therapy authorization.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyBavencio (avelumab) (Intravenous) Coverage CriteriaThis policy governs prior authorization, dosing, initial approval, and renewal requirements for intravenous Bavencio (avelumab) for adult and specified pediatric members with eligible malignancies. Coverage requires indication-specific clinical criteria, and renewal requires ongoing benefit without unacceptable toxicity.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyCasgevy (exagamglogene autotemcel) Coverage CriteriaPrior authorization and coverage criteria for one treatment course of Casgevy for eligible members with severe symptomatic sickle cell disease or transfusion-dependent beta thalassemia.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyCinryze (C1 Esterase Inhibitor, Human) for Hereditary Angioedema ProphylaxisThis policy governs prior authorization, coverage criteria, dosing, renewal, and billing for intravenous Cinryze used to prevent hereditary angioedema attacks for Viva Health Plan commercial members and their providers.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyElitek (rasburicase) Coverage CriteriaThis policy governs prior authorization, medical necessity, dosing, and billing requirements for intravenous Elitek (rasburicase) used to prevent or treat hyperuricemia associated with tumor lysis in Viva Health Plan members receiving chemotherapy for leukemia, lymphoma, or solid tumors.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyExdensur (depemokimab-ulaa) Coverage CriteriaThis policy governs prior authorization coverage for subcutaneous Exdensur (depemokimab-ulaa), including initial approval, renewal, dosing limits, continuation therapy, clinical eligibility, concomitant immunomodulator use, and contraindications. It applies to providers requesting Exdensur for plan members.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyFyarro (sirolimus albumin-bound) intravenous therapyThis policy governs prior authorization, coverage criteria, dosing, renewal, and billing for intravenous Fyarro in adult members with specified advanced or metastatic PEComa-related disease.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyHaegarda (C1 Esterase Inhibitor Subcutaneous [Human]) Coverage CriteriaThis policy governs prior authorization, medical necessity, dosing, billing, and renewal requirements for Haegarda used to prevent hereditary angioedema attacks for Viva Health Plan members.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyHemophilia Products – Coagulation Factor XIII A-subunit: Tretten® (Intravenous)This policy governs prior authorization, dosing, dispensing, and renewal of Tretten for routine bleeding prophylaxis in members with congenital factor XIII A-subunit deficiency.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyIntrauterine Device (IUD) for Endometrial HyperplasiaThis policy governs medical necessity, authorization, documentation, and billing for a progestin-containing IUD used to manage endometrial hyperplasia for VIVA Medicare members.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyIntravitreal Lytenava (bevacizumab-vikg) for neovascular age-related macular degenerationThis policy governs prior authorization, dosing, coverage criteria, renewal, and billing for intravitreal Lytenava in adult members with neovascular (wet) age-related macular degeneration for Viva Health Plan commercial and Medicare Advantage provider-administered drug coverage.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyLeqvio (inclisiran) Subcutaneous Coverage CriteriaThis policy governs prior authorization, dosing, billing, and renewal criteria for Leqvio (inclisiran) used to lower LDL-C in adults with hypercholesterolemia, members with heterozygous familial hypercholesterolemia, and members ages 12 to 17 with homozygous familial hypercholesterolemia.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyLevocarnitine InjectionThis policy establishes medical necessity criteria for levocarnitine injection for VIVA Medicare and VIVA Commercial members. Coverage requires an FDA-approved indication, compliance with applicable Medicare requirements, and medical-record documentation supporting medical necessity.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyLong-Acting Granulocyte Colony-Stimulating Factors (LA-GCSF)This policy governs prior authorization, coverage criteria, dosing, authorization duration, and billing for subcutaneous long-acting granulocyte colony-stimulating factors used for chemotherapy-associated neutropenia, radiation exposure, transplantation-related indications, and specified oncology indications for Viva Health Plan commercial members.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyLoqtorzi (toripalimab-tpzi) (Intravenous)This policy governs prior authorization, medical necessity, dosing, renewal, and billing requirements for intravenous Loqtorzi in adults with specified head and neck, gastrointestinal, and anal cancers.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyProton Beam Radiotherapy (PBRT) Coverage CriteriaEstablishes medical-necessity and utilization-review requirements for proton beam radiotherapy for all lines of business, with additional clinical-trial or registry requirements for specified Medicare diagnoses.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyProton Beam Radiotherapy (PBRT) UR Guidelines 029 Policy and ProcedureThis policy establishes medical necessity and coverage criteria for proton beam radiotherapy (PBRT) for Viva Health members across applicable lines of business. It governs provider requests, required medical review, qualifying diagnoses, clinical circumstances, and associated CPT coding.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyPyridoxine Hydrochloride Injection Coverage CriteriaEstablishes medical necessity and utilization review requirements for pyridoxine hydrochloride injection for VIVA Medicare and VIVA Commercial members. Coverage is limited to FDA-approved indications and requires medical-record documentation supporting medical necessity.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyRuconest (C1 Esterase Inhibitor [recombinant]) Intravenous Therapy for Acute Hereditary Angioedema AttacksThis policy governs prior authorization, dosing, quantity limits, and coverage criteria for intravenous Ruconest used to treat acute hereditary angioedema attacks in Viva Health Plan commercial members age 13 years and older who meet specified specialist, safety, diagnostic, and clinical criteria.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyRytelo (imetelstat) Intravenous TherapyThis policy governs prior authorization, dosing, renewal, and coverage criteria for intravenous Rytelo (imetelstat) for adult members with myelodysplastic syndromes. It applies to providers requesting coverage under the Viva Health Plan medical benefit.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicySarclisa Escena (isatuximab-irfc) Subcutaneous TherapyThis policy governs prior authorization, medical necessity, dosing, administration, and renewal requirements for Sarclisa Escena subcutaneous therapy in adults with multiple myeloma-related indications. It applies to providers requesting coverage under Viva Health Plan.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicySpravato (esketamine) (Intranasal)This policy governs prior authorization, coverage criteria, dosing limits, administration, renewal, and billing requirements for Spravato (esketamine) nasal spray for adults with major depressive disorder. It applies to Viva Health Plan commercial and Medicare fee-for-service members and their providers.All vivahealthplan updates
- Coverage CriteriaClinical/Medical PolicyTecelra (afamitresgene autoleucel) Coverage CriteriaThis policy governs prior authorization, medical necessity, dosing, administration, and billing requirements for Tecelra, an intravenous autologous T-cell therapy used for eligible patients with unresectable or advanced/metastatic synovial sarcoma.All vivahealthplan updates
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Tool Description
Search Vivahealthplan 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
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