Washington State Health Care Authority Coverage Criteria
- Washington State Health Care Authority prior authorization
- All Washington State Health Care Authority policy updates
Latest Washington State Health Care Authority coverage criteria updates22
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01MethadoneWashington State Health Care Authority Medicaid fee-for-service coverage and prior authorization requirements for methadone products, including clinical criteria, dose and quantity limits, documentation, billing codes, and approval durations.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-08-01Transmucosal Fentanyl ProductsPrior authorization and medical necessity criteria for transmucosal fentanyl products used to treat breakthrough cancer pain in patients receiving around-the-clock opioid therapy for persistent cancer pain through Washington State Health Care Authority Apple Health fee-for-service.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-06-01Movement Disorder Agents: Valbenazine (Ingrezza)Prior authorization and medical-necessity coverage for valbenazine (Ingrezza) to treat Huntington disease chorea and tardive dyskinesia in Apple Health members, including clinical criteria, reauthorization, prescriber qualifications, exclusions, step therapy, and quantity limits.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-04-01Adenosine Triphosphate-Citrate Lyase InhibitorsApple Health fee-for-service prior authorization for Nexletol and Nexlizet in adults with cardiovascular risk or primary hyperlipidemia, including heterozygous familial hypercholesterolemia.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2026-02-01Vasopressin Receptor Antagonists - OralThis policy governs Washington Apple Health prior authorization and medical-necessity coverage for oral tolvaptan products used for autosomal dominant polycystic kidney disease and hypervolemic or euvolemic hyponatremia. It applies to providers requesting coverage for generic tolvaptan, Jynarque, or Samsca.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-07-01Cytokine and CAM Antagonists: Integrin Receptor AntagonistsThis policy governs prior authorization and medical-necessity coverage for vedolizumab (Entyvio and Entyvio Pen) for adults with moderate-to-severe Crohn’s disease or ulcerative colitis, including clinical criteria, preferred-drug step therapy, reauthorization, quantity limits, and billing coding.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Bone Density Regulators - CalcitoninsWashington Apple Health coverage and prior authorization for calcitonin-salmon products used for hypercalcemia, Paget's disease, and postmenopausal osteoporosis, including clinical criteria, preferred-drug trials, reauthorization, dosage, and quantity limits.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-06-01Bone Density Regulators - RANKL InhibitorsThis policy governs Washington Apple Health fee-for-service prior authorization and medical-necessity review for the RANKL inhibitors denosumab (Prolia and Xgeva). It establishes indication-specific clinical criteria, preferred-drug step therapy, reauthorization requirements, dosing limits, and billing information.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-05-01Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)Washington Apple Health coverage and prior authorization requirements for Zepbound (tirzepatide) in adults with obesity and moderate to severe obstructive sleep apnea, including initial authorization, reauthorization, preferred-drug sequencing, documentation, and dosage requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-08-01Androgen Biosynthesis Inhibitors - AbirateroneThis policy governs Apple Health coverage and prior authorization for abiraterone (Yonsa and Zytiga) for specified prostate cancer indications, including initial and reauthorization criteria, preferred-drug requirements, concurrent therapies, dosage limits, and documentation requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-04-01Ophthalmic Agents: Cenegermin-bkbj (Oxervate)This policy governs Washington Apple Health coverage and prior authorization for cenegermin-bkbj (Oxervate) ophthalmic solution for patients with neurotrophic keratitis, including clinical criteria, dosing limits, and lifetime treatment restrictions.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-12-01Elapegademase-lvlr (Revcovi) Coverage CriteriaPrior authorization and medical-necessity coverage for elapegademase-lvlr (Revcovi) in pediatric and adult clients with ADA-SCID, including initial therapy, reauthorization, monitoring, dosing, and quantity requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-05-01Atopic Dermatitis Agents: Crisaborole (Eucrisa)This policy governs prior authorization and medical-necessity coverage for topical crisaborole (Eucrisa) for atopic dermatitis under Washington Apple Health, including initial approval, reauthorization, prior topical therapies, documentation, authorization duration, and quantity limits.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-07-01Brineura (cerliponase alfa) coverage criteriaThis policy governs medical necessity and prior authorization for Brineura in pediatric patients with late infantile neuronal ceroid lipofuscinosis type 2 (CLN2), also known as tripeptidyl peptidase 1 deficiency.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-10-01Pulmonary Fibrosis AgentsThis policy governs prior authorization and medical-necessity coverage for nintedanib (Ofev) and pirfenidone (Esbriet) used to treat confirmed idiopathic pulmonary fibrosis for Apple Health clients receiving Washington Medicaid fee-for-service or managed care coverage.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-07-01Multiple Sclerosis Agents – Dalfampridine (Ampyra)This policy governs prior authorization and coverage of dalfampridine (Ampyra) to improve walking in adults with multiple sclerosis, including approval criteria, reauthorization, dosing, quantity limits, and clinical eligibility requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyAmylin AnalogsThis policy governs medical necessity, initial authorization, reauthorization, and quantity limits for pramlintide products used as an adjunct to mealtime insulin in members with type 1 or type 2 diabetes. Coverage requires inadequate glycemic control despite optimal insulin therapy and satisfaction of specified clinical criteria.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyDental Treatment Coverage and Dental NecessityThis document explains that the Uniform Dental Plan and DeltaCare do not require preauthorization for dental treatment. Treatment is covered only when it is dentally necessary, satisfies the stated clinical criteria, and is included under the applicable plan benefits.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyMedically Necessary Contact Lens Clinical CriteriaThis policy establishes clinical criteria for medically necessary or visually required contact lenses and related low-vision services. Coverage is limited to members with specified diagnoses and documented clinical findings, with Medicare-specific decision-making and billing requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyMedically Necessary Contact Lens Clinical CriteriaDefines diagnoses, clinical findings, documentation, and coding requirements for medically necessary or visually required contact lenses in Washington, with Medicare coverage hierarchy rules.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyTelemedicine Policy - Apple Health Obstetric CareProposed coverage criteria for obstetric telemedicine services for Apple Health clients, including medical necessity, safety, hybrid-care, provider, documentation, prenatal, postpartum, billing, and audio-only requirements.All Washington State Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyUrinalysis Drug Testing for Substance Use Disorder TreatmentGuidance for coverage of urinalysis drug screening and confirmation testing for Apple Health members receiving medication for substance use disorder or formal substance use disorder treatment; excludes workplace and court-ordered or diversion-program testing.All Washington State Health Care Authority updates
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Tool Description
Search Washington State Health Care Authority 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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