Ambetter Georgia Prior Authorization Lookup
Latest Ambetter Georgia prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Glucagon-Like Peptide-1 (GLP-1) Receptor Agonists Weight Management Benefit for Pediatric MembersDefines medical necessity and prior authorization criteria for liraglutide (Saxenda), semaglutide (Wegovy), and tirzepatide (Zepbound) when used for chronic weight management in pediatric members under the EPSDT benefit for Ambetter Georgia Medicaid plans.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Berotralstat (Orladeyo) and assorted pharmacy prior authorization updatesCovers prior authorization, coding, and coverage-related updates for multiple pharmacy policies with a primary heading of Berotralstat (Orladeyo); affects Ambetter Georgia providers requesting pharmacy-covered medications listed in the document.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-01Clinical Policy: Suzetrigine (Journavx)Defines medical necessity and prior authorization criteria for suzetrigine (Journavx) for adults with moderate to severe acute pain, including postoperative pain, across Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2024-11-13Eladocagene Exuparvovec-tneq (Kebilidi) coverageDefines medical necessity and prior authorization requirements for Kebilidi gene therapy for AADC deficiency for Ambetter Georgia lines of business (Commercial, HIM, Medicaid). Applies to providers requesting coverage for the drug.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-01Clinical Policy: PretomanidPolicy governing medical necessity and prior authorization criteria for pretomanid when used as part of a combination regimen (bedaquiline and linezolid) to treat specified drug-resistant pulmonary tuberculosis in Ambetter Georgia members.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-01Musculoskeletal (MSK) Surgery Prior Authorization ProgramDefines prior authorization requirements for non-emergent outpatient and inpatient hip, knee, shoulder, lumbar and cervical surgeries for Ambetter of Alabama members and informs participating providers about NIA-managed authorization processes.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2023-10-17Zilucoplan (Zilbrysq) for generalized myasthenia gravisClinical policy governing prior authorization and coverage criteria for Zilbrysq (zilucoplan) for treatment of generalized myasthenia gravis in adults under Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthAdministrative/Operational PolicyEff. 2023-09-08Privacy Notice — Uses and Disclosures of Protected Health Information (PHI)This notice explains how Ambetter Georgia may use, disclose, protect, and allow access to members' protected health information (PHI), and describes member rights and situations when PHI may be used or disclosed without prior authorization. It applies to members of Ambetter Georgia as described in the notice.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2023-03-01Futibatinib (Lytgobi) coverage for cholangiocarcinomaThis policy defines medical necessity and prior authorization criteria for futibatinib (Lytgobi) for members of Ambetter Georgia across Commercial, HIM, and Medicaid lines of business; it governs initial and continued coverage for cholangiocarcinoma and guidance for other indications. Providers must supply supporting clinical documentation to obtain approval.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2023-03-01Tremelimumab-actl (Imjudo) coverage policyDefines medical necessity and prior authorization requirements for tremelimumab-actl (Imjudo) for Ambetter Georgia members across commercial, HIM, and Medicaid lines of business, including FDA-approved and select NCCN-recommended off-label uses in combination with durvalumab.All Ambetter Georgia updates
- Prior AuthAdministrative/Operational PolicyEff. 2022-10-01House Bill 3459 Preauthorization Exemption ProgramDescribes Ambetter Georgia's implementation of Texas House Bill 3459 allowing certain providers to be exempt from prior authorization for specific services, procedures, or drugs when they meet performance thresholds; applies to Ambetter programs (excluding Medicare/Medicaid) and is limited to Texas Ambetter Health providers for consideration.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2022-06-01Clinical Policy: Rifamycin (Aemcolo)Defines medical necessity and prior authorization criteria for Aemcolo (rifamycin) use, primarily for treatment of travelers' diarrhea in adults, and applies to Ambetter Georgia lines of business including Commercial, HIM/ICHRA, and Medicaid.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2022-03-01Sirolimus Protein-Bound Particles (Fyarro) and Topical Sirolimus Gel (Hyftor)This policy defines medical necessity and prior authorization criteria for Fyarro (IV sirolimus protein-bound particles) for PEComa and Hyftor (topical sirolimus gel) for facial angiofibroma in tuberous sclerosis, and describes approval durations and dosing limits for affected members under Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthAdministrative/Operational PolicyEff. 2022-01-01Prior Authorization Program for Outpatient Physical Medicine ServicesGoverns prior authorization requirements and NIA/RadMD workflows for outpatient physical, occupational, and speech therapy services provided to Ambetter from Nebraska Total Care members.All Ambetter Georgia updates
- Prior AuthAdministrative/Operational PolicyEff. 2021-12-01Oncology and hematology prior authorization and utilization managementGoverns authorization requirements and referral to New Century Health (NCH) for oncology, hematology, radiation oncology, and related transplant chemotherapy services for Ambetter From Magnolia Health members; applies to adult and pediatric providers and membership.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-16Clinical Policy: Obeticholic Acid (Ocaliva)Defines medical necessity, prior authorization, and continuation criteria for obeticholic acid (Ocaliva) for treatment of primary biliary cholangitis (PBC) for Ambetter Georgia lines of business. Applies to providers requesting initiation or continuation of therapy under Centene-affiliated health plans.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-07-16Clinical Policy: Golimumab (Simponi, Simponi Aria)Defines medical necessity, prior authorization, and coverage criteria for golimumab (Simponi and Simponi Aria) for Ambetter Georgia Medicaid members across labeled indications and continuation therapy.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-06-01Clinical Policy: Insulin Delivery Systems (V-Go, Omnipod, InPen)Defines prior authorization, medical necessity, and approval durations for specified insulin delivery systems (V-Go, Omnipod family, InPen) for Ambetter Georgia members across Commercial, Medicaid, and HIM medical benefits.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-06-01Clinical Policy: Insulin Delivery Systems (V-Go, Omnipod, InPen)Prior authorization and medical necessity criteria for wearable and smart insulin delivery systems (V-Go, Omnipod variants, InPen) for Ambetter Georgia members across commercial, HIM, and Medicaid lines of business.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-05-01Dabigatran (Pradaxa) Coverage CriteriaCriteria and prior authorization rules for coverage of dabigatran (Pradaxa) for Ambetter Georgia Medicaid members, including indications, initial and continued therapy requirements, dosing limits, contraindications, and documentation requirements.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-04-01Clinical Pharmacy Services Inter-Rater ReliabilityDefines the Ambetter Georgia (Peach State Health Plan) Pharmacy Department process for annual inter-rater reliability testing of clinical pharmacists performing prior authorization reviews to ensure consistent application of PA criteria and clinical decision making.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-03-16Clinical Policy: Tadalafil (Adcirca, Alyq)Defines medical necessity, prior authorization, and approval durations for Adcirca and Alyq (tadalafil) for treatment of pulmonary arterial hypertension (PAH) for Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-03-16Selexipag (Uptravi) coverageDefines medical necessity and prior authorization criteria for selexipag (Uptravi) for treatment of pulmonary arterial hypertension (PAH) and related coverage rules for Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2021-02-19Clinical Policy: Enzalutamide (Xtandi)Defines medical necessity and authorization criteria for enzalutamide (Xtandi) for members with castration-resistant or metastatic castration-sensitive prostate cancer and governs prior authorization and continuation for Ambetter Georgia lines of business.All Ambetter Georgia updates
- Prior AuthClinical/Medical PolicyEff. 2020-11-16Obeticholic acid (Ocaliva) coverageDefines medical necessity, prior authorization, and coverage criteria for obeticholic acid (Ocaliva) for Ambetter Georgia members across commercial, HIM, and Medicaid lines of business. Applies to providers requesting coverage for PBC and (pending) NASH indications.All Ambetter Georgia updates
1–25 of 306
1 / 13
Tool Description
Search Ambetter Georgiaprior 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.
Prior Authorization by Payer
Go deeper
Explore OpenPayer Data
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.
Toolbox
More OpenPayer Tools
- Billing Code LookupSearch CPT, HCPCS, J-codes, DRG, and dental codes by number or procedure name.
- Healthcare Provider & Facility LookupFind hospitals and healthcare facilities by name, taxonomy, facility type, ownership, or state.
- Health Insurance Payer LookupSearch national health insurance payers and health plans by name and state presence.
- Provider Taxonomy Code LookupSearch NUCC taxonomy codes by code, specialty, grouping, or classification.
- CPT Modifier LookupSearch CPT modifiers by code or name — descriptions, when to use them, and payer policy context.
- Timely Filing LookupFind payer timely filing policies: claim deadlines, corrected claim windows, and appeal timeframes.
- Coverage Criteria LookupSearch payer coverage criteria and medical necessity requirements by drug, procedure, or payer.
- Payer Contact DirectoryClaims, prior authorization, provider services, and appeals contacts for health insurance payers.
Published by
Trek Health powers OpenPayer with a leading commercial payer intelligence platform, seamlessly converting fragmented payer data into actionable insights for provider organizations.