Advancedhealth Prior Authorization Lookup
Latest Advancedhealth prior authorization updates25
- Prior AuthClinical/Medical PolicyButalbital-Containing Products Drug Use CriteriaThis policy governs prior authorization and coverage criteria for butalbital-containing products used by Oregon Health Plan members for headaches. It applies to requests for acute treatment of chronic migraine, tension-type headache, or acute migraine, with age, pregnancy, medication-overuse, severity, and prior-treatment requirements.All advancedhealth updates
- Prior AuthClinical/Medical PolicyCardiac Myosin Inhibitors Drug Use CriteriaThis policy governs prior authorization, initial approval, renewal, dosing, dispensing, and monitoring requirements for Myqorzo (aficamten) and Camzyos (mavacamten) in members requesting therapy for symptomatic obstructive hypertrophic cardiomyopathy, including eligible adults and pediatric Camzyos patients weighing at least 30 kg.All advancedhealth updates
- Prior AuthClinical/Medical PolicyContinuous Glucose Monitor (CGM) Use CriteriaThis policy governs prior authorization for initial and renewal coverage of continuous glucose monitors and supplies for members with insulin-treated diabetes. It applies to provider-submitted requests requiring documentation of appropriate diabetes treatment, education, CGM utilization, and clinical benefit.All advancedhealth updates
- Prior AuthClinical/Medical PolicyDenosumab (Prolia) Drug Use CriteriaThis policy governs prior authorization and renewal of Prolia (denosumab) for osteoporosis and selected cancer-treatment-related bone loss indications. Coverage is limited to members meeting specified fracture-risk, alternative-treatment, biosimilar-preference, clinical-benefit, and monitoring requirements.All advancedhealth updates
- Prior AuthClinical/Medical PolicyDenosumab (Xgeva) Drug Use CriteriaThis policy governs prior authorization for Xgeva (denosumab) for members with specified malignancy-related bone conditions, giant cell tumor of bone, or hypercalcemia of malignancy. It establishes initial-therapy alternatives, preferred biosimilar requirements, approval duration, and renewal criteria.All advancedhealth updates
- Prior AuthClinical/Medical PolicyEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT) Drug Use CriteriaThis policy governs prior authorization review for medications requested for Advanced Health members age 20 and younger under EPSDT. It establishes formulary, FDA approval or compendium support, medical-severity, and medical-necessity requirements for coverage.All advancedhealth updates
- Prior AuthClinical/Medical PolicyFecal Microbiota Drug Use CriteriaThis policy governs prior authorization and coverage of Rebyota and Vowst to prevent recurrence of Clostridioides difficile infection in adults with recurrent CDI for Advanced Health members.All advancedhealth updates
- Prior AuthClinical/Medical PolicyGeneral Drug Use Criteria for Prior AuthorizationsEstablishes general coverage and prior authorization requirements for non-formulary medications and formulary medications requiring pre-approval when no drug-specific criteria exist for Advanced Health Oregon Health Plan members, including initial and renewal requests.All advancedhealth updates
- Prior AuthClinical/Medical PolicyGlucagon-like Peptide-1 (GLP-1) Receptor Agonists and Glucose Dependent Insulinotropic Polypeptide (GIP) Receptor Agonist Drug Use CriteriaThis policy governs prior authorization, step therapy, initial approval, and renewal of selected GLP-1 receptor agonists and tirzepatide for members with type 2 diabetes mellitus. Adult weight-loss use is not covered under this pathway; Wegovy and Zepbound follow separate criteria.All advancedhealth updates
- Prior AuthClinical/Medical PolicyHepatitis C Direct-Acting Antiviral TherapyCoverage and prior authorization for direct-acting antiviral regimens used to treat hepatitis C infection in adults, adolescents, and children, based on genotype, prior treatment, cirrhosis status, age, and safety considerations.All advancedhealth updates
- Prior AuthClinical/Medical PolicyIngrezza (Valbenazine) Drug Use CriteriaPrior authorization and renewal criteria for Ingrezza (valbenazine) in adults with tardive dyskinesia or chorea associated with Huntington's disease.All advancedhealth updates
- Prior AuthClinical/Medical PolicyInjectable Epinephrine Drug Use CriteriaThis policy governs Advanced Health coverage of injectable epinephrine products for Oregon members, including annual quantity limits, formulary selection, prior authorization requirements, documentation, and exclusions for convenience or multiple-site storage.All advancedhealth updates
- Prior AuthClinical/Medical PolicyIntranasal Corticosteroids Drug Use CriteriaThis policy governs coverage and prior authorization for intranasal corticosteroids under the Oregon Health Plan, including preferred-agent sequencing, covered diagnoses, formulary exceptions, and least-cost alternative requirements.All advancedhealth updates
- Prior AuthClinical/Medical PolicyIntravenous Iron Drug Use CriteriaThis policy governs prior authorization and medical-necessity criteria for selected intravenous iron products used to treat iron deficiency anemia or iron deficiency without anemia. It applies to members requesting covered intravenous iron drugs; Venofer (iron sucrose) does not require prior authorization.All advancedhealth updates
- Prior AuthClinical/Medical PolicyKetorolac Drug Use CriteriaThis policy governs prior authorization and coverage of oral ketorolac tablets prescribed for outpatient use under the Oregon Health Plan. Injectable ketorolac administered in a provider office is excluded from these criteria.All advancedhealth updates
- Prior AuthClinical/Medical PolicyLevetiracetam XR Drug Use CriteriaThis policy governs prior authorization and renewal requirements for levetiracetam extended-release products, including Keppra XR and generic levetiracetam XR, for Advanced Health members seeking treatment for epilepsy or seizure disorders.All advancedhealth updates
- Prior AuthClinical/Medical PolicyLong-Acting Stimulant Criteria for Patients 6-22 Years OldThis policy governs prior authorization and formulary exception coverage for extended-release stimulant medications in Advanced Health members ages 6 through 22. Coverage requires FDA-supported dosing and generally requires failure of formulary extended-release stimulant therapy or satisfaction of specified clinical exceptions.All advancedhealth updates
- Prior AuthClinical/Medical PolicyMultaq (dronedarone) Drug Use CriteriaThis policy governs prior authorization and coverage of Multaq (dronedarone) for Oregon Health Plan members. Coverage requires an FDA-approved indication, cardiologist prescribing or supervision, absence of specified high-risk conditions, and failure of or contraindication to amiodarone.All advancedhealth updates
- Prior AuthClinical/Medical PolicyMyasthenia Gravis Agents Drug Use CriteriaThis policy governs prior authorization for selected agents used to treat generalized myasthenia gravis in Advanced Health Medicaid members, including initial and renewal requirements for FDA-labeled use, adult age, specialist prescribing, disease severity, antibody status, prior therapy, laboratory thresholds, dosing, and clinical benefit.All advancedhealth updates
- Prior AuthClinical/Medical PolicyNebulizer Machine (Compressor and Accessories) Use CriteriaGoverns prior authorization for initial and renewal requests for nebulizer systems, compressors, and related accessories for Advanced Health members under Oregon Health Authority criteria.All advancedhealth updates
- Prior AuthClinical/Medical PolicyNon-Preferred Inhaler Drug Use CriteriaThis policy governs prior authorization and medical-necessity review for non-preferred inhalers used for funded asthma, COPD, or qualifying comorbid conditions. It requires an FDA-approved indication and adequate trial and failure of a preferred inhaler, with separate renewal durations for asthma and COPD.All advancedhealth updates
- Prior AuthClinical/Medical PolicyNon-Preferred Insulin Drug Use CriteriaThis policy governs prior authorization for non-preferred insulin products. Coverage is available when the member has failed or cannot use a preferred formulary insulin, or when documentation supports why a preferred product cannot be used.All advancedhealth updates
- Prior AuthClinical/Medical PolicyOpioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety EditsThis policy governs coverage, prior authorization, quantity limits, safety edits, and documentation requirements for chronic opioid therapy and acute opioid prescriptions that exceed SUPPORT Act safety thresholds. It applies to opioid prescriptions covered by Advanced Health, with explicit exemptions for hospice, palliative care, cancer treatment, certain long-term care residents, and sickle cell disease.All advancedhealth updates
- Prior AuthClinical/Medical PolicyOpioid Drug Use Policy for Chronic Non-Malignant Pain and Acute Opioid Prescriptions Exceeding SUPPORT ACT Safety EditsThis policy governs coverage, prior authorization, safety edits, quantity limits, and tapering requirements for chronic opioid therapy and acute opioid prescriptions that exceed SUPPORT Act safety thresholds. It applies to providers prescribing opioids for eligible Oregon Health Plan-funded conditions, subject to stated exclusions and exceptions.All advancedhealth updates
- Prior AuthClinical/Medical PolicyOrilissa Drug Use CriteriaThis policy governs prior authorization for Orilissa used to manage moderate to severe endometriosis-associated pain in adult women. It establishes required prior therapies, hepatic-function criteria, treatment-duration limits, renewal requirements, and denial conditions.All advancedhealth updates
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Tool Description
Search Advancedhealthprior authorization policies by drug name, procedure, or policy title. Results include any policy that mentions prior authorization requirements (drug coverage criteria, imaging guidelines, site-of-service rules) not just documents titled “prior authorization.” Every result links to a full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
Filter by payer, specialty, policy type, or effective year; or search directly for a drug (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee arthroplasty”), or a policy number.
Coverage spans 110+ payers. Jump straight to the busiest prior-auth publishers: UnitedHealthcare, Cigna, Aetna, Anthem, and Centene. You can also browse the full policy updates feed.
Pair a prior-auth search with the billing code lookup to confirm the CPT or J-code on the claim, the payer lookup for plan footprint, and payer profiles for contacts and coverage context.
FAQ
Type a drug name (“Wegovy,” “Ozempic”), a procedure (“MRI,” “knee”), or a policy title into the search bar. Filter results by payer, specialty, policy type, or effective year. Open any result for the full policy page with clinical criteria, covered billing codes, documentation requirements, and effective dates.
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Prior auth requirements change all the time. Keep up with every payer policy update in the live policy feed, or browse payers with prior authorization policies.
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