AvMed Prior Authorization Lookup
Latest AvMed prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-07-01AvMed Employer Plans 4-Tier Prescription Drug FormularyRules and guidance for prescription drug coverage, formulary tiers, pharmacy use, prior authorization, and related pharmacy benefit processes for AvMed employer plan members.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01AvMed Employer Plans 5-Tier Prescription Drug FormularyDefines AvMed Employer Plans' prescription drug formulary structure, coverage rules, prior authorization and pharmacy use requirements for members and providers under the employer plan.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Individual and Family Plans 5-Tier Prescription Drug Formulary (Non-Standard Plan)Defines AvMed's 5-tier prescription drug formulary for individual and family plans, including coverage structure, prior authorization and exceptions procedures, and member/pharmacy requirements; affects AvMed members and in-network prescribers/pharmacies.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Small Group ACA 5-Tier Prescription Drug Formulary (Non-Standard Plan)Defines AvMed's non-standard 5-tier prescription drug formulary for small group ACA employer plans, including formulary structure, coverage processes (prior authorization, step therapy, quantity limits), exclusions, and member pharmacy requirements; affects members and prescribers using this plan.All AvMed updates
- Prior AuthAdministrative/Operational PolicyEff. 2025-12-19Medical Prior Authorization Requirements / Medical Procedures GuidelinesGoverns AvMed's prior authorization requirements, delegates, and processes for medical procedures and services for all AvMed members and product lines; affects providers (in-network and out-of-network), delegated vendors, and members in North Carolina and nationally where specified.All AvMed updates
- Prior AuthAdministrative/Operational PolicyEff. 2024-04-04Medical Prior Authorization RequirementsDefines AvMed's prior authorization requirements, vendors/delegates for specific service types, turnaround times, and which members/plans are affected; applies to all AvMed members and benefit products. Providers (in- and out-of-network) must verify eligibility and obtain authorizations when required.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2023-07-26Prior authorization and coverage criteria for Vyleesi (bremelanotide)This document is a prior authorization/step-edit request form and clinical criteria for coverage of Vyleesi (bremelanotide) for members of AvMed. It governs prescriber submission requirements and clinical eligibility for Vyleesi therapy.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Abecma (idecabtagene vicleucel) IV prior authorizationPrior authorization form and medical necessity criteria for Abecma (idecabtagene vicleucel) IV (HCPCS Q2055) for treatment of relapsed or refractory multiple myeloma, including provider, patient, dosing, quantity limits, and required clinical documentation.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Abrysvo (RSV vaccine) for Active Immunization of Pregnancy — Prior Authorization and Coverage CriteriaDefines prior authorization and clinical criteria for covering Abrysvo (RSV vaccine) during pregnancy for AvMed members; applies to providers requesting medical (office-administered) coverage. Affects pregnant members and prescribers submitting PA requests.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Actimmune (interferon gamma-1b) prior authorizationThis document governs prior authorization and step-edit requests for Actimmune (interferon gamma-1b) for AvMed members, specifying required prescriber signatures, clinical criteria for Chronic Granulomatous Disease and severe malignant osteopetrosis, and documentation needed for approval.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Adakveo (crizanlizumab-tmca) prior authorizationRequirements and clinical criteria for AvMed medical prior authorization of Adakveo (crizanlizumab-tmca) for reducing vaso-occlusive crises in patients with sickle cell disease; applies to providers requesting coverage for the medication.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Adasuve (loxapine) medical prior authorizationThis form governs prior authorization and step-edit requests for Adasuve (loxapine aerosol) administered as an outpatient/medical benefit and applies to AvMed members and their prescribing providers.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Adstiladrin (nadofaragene firadenovec-vncg) prior authorization — Non‑muscle invasive bladder cancerRequirements and clinical criteria for prior authorization of Adstiladrin (J9029) for treatment of non‑muscle invasive bladder cancer in AvMed members; intended for prescribing providers and facility staff submitting PA/step-edit requests.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aduhelm (aducanumab) prior authorization — medical necessity and monitoring criteriaMedical prior authorization criteria and dosing/monitoring requirements for Aduhelm (aducanumab) IV for AvMed members; applies to prescribers and administering facilities seeking coverage for Aduhelm infusions.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Adzynma (ADAMTS13 recombinant-krhn) — Prior Authorization for congenital TTP (cTTP)Prior authorization and clinical criteria for medical (clinic/infusion) use of Adzynma for congenital thrombotic thrombocytopenic purpura (cTTP) for AvMed members; applies to providers requesting coverage of prophylactic or on-demand therapy.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aflibercept (Eylea) for Retinopathy of Prematurity — Prior Authorization Coverage CriteriaPrior authorization form and clinical criteria for coverage of Eylea (aflibercept J0177) for treatment of Retinopathy of Prematurity (ROP) in premature infants; intended for AvMed providers requesting outpatient drug approval.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aldurazyme (laronidase) prior authorization for MPS IRequirements and clinical criteria for prior authorization and continuation of intravenous Aldurazyme (laronidase) for members with mucopolysaccharidosis type I (MPS I); applies to providers requesting medical benefit coverage from AvMed.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aliqopa (copanlisib) IV prior authorization for relapsed follicular lymphomaCovers medical prior authorization requirements for Aliqopa (copanlisib) administered IV for AvMed members; describes required provider, member, and clinical documentation and criteria for approval. Affects prescribers, administering sites, and members seeking coverage for this drug.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Alpha Proteinase Inhibitors (Medical)Prior authorization policy for intravenous alpha-1 antitrypsin (AAT) augmentation therapy (Aralast NP, Glassia, Prolastin-C, Zemaira) including initial and continuation authorization clinical criteria, quantity limits (NDCs/HCPCS units), and administrative submission requirements for AvMed members.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Amphotericin B liposome (AmBisome) prior authorizationDefines AvMed medical prior authorization and step-edit criteria for amphotericin B liposome (AmBisome) for outpatient medical administration, including required documentation, eligible diagnoses, prescriber requirements, and reauthorization conditions for members.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Amtagvi (lifileucel) medical prior authorizationPrior authorization form and medical coverage criteria for Amtagvi (lifileucel) administered under the medical benefit (J9999). Defines patient eligibility, clinical exclusion criteria, dosing limits, provider and site requirements, and documentation/submission instructions for approval of a single lifetime treatment course.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Amvuttra (vutrisiran) prior authorization for transthyretin amyloidosisThis AvMed medical prior authorization/step-edit form governs coverage and authorization requirements for Amvuttra (vutrisiran) for members with transthyretin-mediated polyneuropathy or cardiomyopathy; it applies to providers seeking medical (non-pharmacy) benefit approval.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aphexda (motixafortide) prior authorization for autologous transplantation in multiple myelomaThis form governs prior authorization and step-edit requests for Aphexda (motixafortide) when used to mobilize stem cells for autologous transplantation in multiple myeloma patients; it affects prescribers, pharmacists, and AvMed members in North Carolina.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Aucatzyl (obecabtagene autoleucel) — Medical Prior Authorization / Coverage CriteriaThis document governs prior authorization and step-edit requests for Aucatzyl (obecabtagene autoleucel) for AvMed members, specifying required documentation, clinical eligibility, dosing, and site-of-care information for providers requesting coverage.All AvMed updates
- Prior AuthClinical/Medical PolicyEff. 2021-11-12Azedra (iobenguane I-131) IV — Prior Authorization and Medical Necessity CriteriaPrior authorization form and medical necessity criteria for AvMed coverage of Azedra (iobenguane I-131) IV for treatment of pheochromocytoma and paraganglioma, affecting providers prescribing or administering the drug for AvMed members in North Carolina.All AvMed updates
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Tool Description
Search AvMedprior 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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