Aloha Care Prior Authorization Lookup
Latest Aloha Care prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-06-012026 AlohaCare Advantage Plus (HMO D-SNP) Drugs with Step Therapy RequirementsLists Aloha Care Advantage Plus (HMO D-SNP) drugs that require trial of preferred therapies (step therapy) before coverage of other listed drugs; applies to prescribers and pharmacy prior authorization reviewers under this plan.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-13Beers Criteria prior authorization for older adultsThis policy requires prior authorization (PA) for medications listed on the American Geriatrics Society Beers Criteria when prescribed to members aged 65 years and older to promote medication safety and reduce use of potentially harmful drugs.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Antiemetics for Oncology (NK1 RA, 5HT3 RA, combination)Policy governing prior authorization, step therapy, and coverage criteria for antiemetic drugs used to prevent or treat chemotherapy-induced nausea and vomiting for Aloha Care members (Medicare and Medicaid specified in places). Affects providers requesting outpatient antiemetic drugs including injectable and oral NK1 RAs, 5HT3 RAs, and combination products.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-01-01Denosumab (Xgeva/Prolia and biosimilars) Medicare coverage criteriaMedicare (and Medicaid) prior authorization, quantity limits, preferred biosimilars, and clinical approval/renewal criteria for denosumab products (Xgeva/Prolia and listed biosimilars) provided under Aloha Care Medicare benefit.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Dose Rounding for Systemic TherapyDefines AlohaCare's policy to implement dose rounding for select systemic cancer therapies (injectable and oral) to reduce waste and cost, affecting providers submitting prior authorizations and administering cancer drugs under pharmacy and medical benefits.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-23Biologic & Immunologic Agents — Coverage and Authorization CriteriaCoverage and authorization criteria for select biologic and immunologic agents (e.g., Actemra, Cosentyx, Entyvio, Orencia, Simponi Aria, Skyrizi, Stelara, Tremfya) for Aloha Care members, including Medicare-specific rules and prior authorization requirements.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-12-23Iron Preparations (Injectable/Intravenous Iron)Defines Aloha Care coverage, prior authorization, and clinical criteria for injectable iron products (e.g., Venofer, Ferrlecit, Injectafer, Feraheme, Monoferric, Triferic, Infed) for members, including Medicare Part B considerations and product-specific approval lengths.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-22Respiratory Interleukins — Coverage CriteriaDefines prior authorization, quantity/duration limits, step therapy, and medical benefit vs pharmacy benefit handling for specified respiratory interleukin biologic agents for Aloha Care members.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-12-22belimumab (Benlysta) coverage and prior authorization policyDefines Aloha Care coverage, prior authorization, dosing, initiation and renewal criteria, exclusions, and administration/site rules for belimumab (Benlysta) for members across applicable benefits (medical for IV, pharmacy for SC). Affects providers prescribing or administering Benlysta and pharmacy/medical benefit reviewers.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-05White Blood Cell Growth Factors (G-CSF / GM-CSF) Coverage CriteriaDefines prior authorization, step therapy, preferred products, and clinical criteria for coverage of FDA‑approved colony stimulating factors (pegfilgrastim, filgrastim, eflapegrastim, efbemalenograstim, sargramostim) for Aloha Care members, including Medicare/Medicaid guidance.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-10-25Alpha-1 Proteinase InhibitorsDefines prior authorization, coverage criteria, and billing/coding guidance for alpha-1 proteinase inhibitor products (Aralast NP, Glassia, Prolastin-C, Zemaira) under Aloha Care; applies to Medicare/Medicaid lines of business and affected providers who request reimbursement.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-25Infliximab (medical benefit) — Medicare Part B coverage and prior authorization criteriaMedicare Part B coverage and prior authorization criteria for infliximab and its biosimilars for Aloha Care Medicare members, including indication-specific requirements and continuation/renewal conditions. Applies to medical benefit administration of infliximab products (J1745 and Q-codes).All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-10-25Nplate (romiplostim) — Medicare Part B coverage and prior authorization criteriaMedicare Part B coverage, prior authorization, and renewal criteria for Nplate (romiplostim) for Aloha Care Medicare members; includes clinical indications, dosing references, and transition/step therapy rules.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-20Rehabilitative Services PolicyDefines medical necessity, coverage criteria, limitations, prior authorization and billing guidance for outpatient physical therapy, occupational therapy, and speech therapy for Aloha Care members.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-10-20Rituximab and Biosimilars (Rituxan, Ruxience, Truxima, Riabni) — Medical Benefit Prior AuthorizationDefines Aloha Care medical benefit coverage, prior authorization, step therapy, and clinical criteria for rituximab and its biosimilars for Medicare and Medicaid populations.All Aloha Care updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-09-11Lack of Information (LOI) PolicyGoverns how AlohaCare and its delegates handle prior authorization requests with insufficient documentation, including outreach attempts, use of fax/phone, and adherence to state regulations; applies to Medicaid and Medicare lines of business and provider interactions for pharmacy and physician-administered drugs.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-09-11Oncology Service Date Revisions (Backdating)This policy governs how AlohaCare handles revisions (backdating) of oncology prior authorization service dates for covered members, outlining allowable justifications and timeframes for making such revisions. It affects providers requesting service date changes and internal Optum/AlohaCare staff processing them.All Aloha Care updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-09-11Urgent and Life‑Threatening PolicyDefines Aloha Care's definition of urgent/life‑threatening cases and the process for designating prior authorizations as urgent; applies to Aloha Care and its delegates and to providers requesting expedited review.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2025-04-02Trastuzumab (Herceptin and biosimilars) Coverage CriteriaMedical policy governing coverage, prior authorization, step therapy, and clinical criteria for trastuzumab and its biosimilars for AlohaCare Medicaid & Medicare members.All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-01-01Collagenase Clostridium Histolyticum (Xiaflex) coverage and prior authorizationDefines medical benefit coverage, prior authorization, dosing limits, and approval/renewal criteria for Xiaflex (collagenase clostridium histolyticum) for Dupuytren's contracture and Peyronie's disease for Aloha Care members.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2023-10-01atezolizumab (Tecentriq) coverageMedical policy governing prior authorization, coverage criteria, and administration of atezolizumab (Tecentriq) for AlohaCare Medicaid and Medicare members.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2023-10-01pembrolizumab (Keytruda) coverageDefines medical benefit coverage, prior authorization, step therapy, and clinical criteria for pembrolizumab (Keytruda) for AlohaCare Medicaid and Medicare members. Applies to requests for therapy supplied under the medical benefit (HCPCS J9271).All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2023-08-17efgartigimod (Vyvgart) — Medicare Part B coverage and prior authorization criteriaMedicare (Part B) coverage, prior authorization, and clinical criteria for efgartigimod products (Vyvgart IV and Vyvgart Hytrulo SC) for treatment of generalized myasthenia gravis in eligible members.All Aloha Care updates
- Prior AuthClinical/Medical PolicyEff. 2019-12-13Genetic Testing Colon Cancer Inherited RiskDefines medical necessity, coverage criteria, prior authorization, and limitations for genetic testing to evaluate inherited colorectal cancer syndromes for Aloha Care members (QUEST Integration Medicaid & Medicare).All Aloha Care updates
- Prior AuthReimbursement/Payment PolicyEff. 2019-05-19Non-Oncology General Prior AuthorizationGoverns prior authorization requirements and approval criteria for non-oncology medications (Medicare and Medicaid lines of business) for Aloha Care members, including Medicare Part B rules and transition provisions.All Aloha Care updates
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Tool Description
Search Aloha Careprior 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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