Care_continuum Prior Authorization Lookup
Latest Care_continuum prior authorization updates14
- Prior AuthClinical/Medical PolicyEff. 2026-05-01Medication coverage change log — specialty drug prior authorization and duration updatesLists recent medication policy changes across multiple specialty drugs for Medicare and Commercial lines, including updated prior authorization, approval durations, diagnostic thresholds, and biosimilar PA additions; affects providers submitting prior authorizations for affected agents.All care_continuum updates
- Prior AuthClinical/Medical PolicyEff. 2025-01-01Continuous Glucose MonitorThis policy governs prior authorization requirements and coverage criteria for prescription continuous glucose monitors (Dexcom and FreeStyle Libre) for Medicare and Commercial members of Care Continuum.All care_continuum updates
- Prior AuthClinical/Medical PolicyEff. 2024-03-01Inflation Reduction Act Impact in 2025 (Pharmacy formulary, PA, QL updates)Describes formulary, prior authorization (PA), quantity limit, and mail-order service changes for Care Continuum (CCUM) driven by IRA-related financial impacts and 2025 program changes; affects Medicare and Commercial lines as specified.All care_continuum updates
- Prior AuthReimbursement/Payment PolicyBalance Billing PolicyDefines Network Health's rules prohibiting providers from balance billing members/participants except for specified member liabilities (deductible, coinsurance, copays) and describes refund and prior-authorization requirements; applies to all lines of business including Commercial and Medicare Advantage.All care_continuum updates
- Prior AuthAdministrative/Operational PolicyCare Continuum (CCUM) management of medical-benefit medicationsDefines how Care Continuum (via EviCore) manages prior authorizations and medical-claim editing for injectable, infusion, and specialty medications under Network Health's medical benefits and how providers interact with the service.All care_continuum updates
- Prior AuthClinical/Medical PolicyCare Continuum — Oral COVID-19 Antivirals and Pharmacy Policy UpdatesSummarizes Care Continuum's COVID-19 clinical guidance (comparison of oral antivirals Paxlovid and Molnupiravir) and pharmacy/formulary changes affecting prior authorization, step therapy, and quantity limits for Medicare and commercial members.All care_continuum updates
- Prior AuthClinical/Medical PolicyClinical Criteria for Utilization Decisions Desk ProcedureDescribes how the Utilization Management department applies nationally recognized and regionally developed utilization criteria and medical policies to prior authorization and coverage determinations for members, including Medicare Advantage, and how UM staff and medical leadership review and apply those criteria.All care_continuum updates
- Prior AuthReimbursement/Payment PolicyHabilitative Services Policy - CommercialDefines billing and administrative requirements for habilitative physical, occupational, and speech therapy services for Commercial line of business members, including modifier use, potential prior authorization, and record review rights; affects Network Health providers and billing staff.All care_continuum updates
- Prior AuthClinical/Medical PolicyHumira Biosimilar Coverage and Pharmacy Program UpdatesDescribes Care Continuum's coverage approach and formulary/prior-authorization updates related to Humira and its biosimilars for Commercial, Medicare, and Healthcare Exchange lines of business; intended for provider and pharmacy staff.All care_continuum updates
- Prior AuthClinical/Medical PolicyInfusion Alternative Site of Care - CommercialDefines criteria and prior authorization requirements determining when outpatient hospital facility-based intravenous medication infusion is medically necessary versus when alternative sites (non-hospital outpatient infusion, physician office, ambulatory infusion, or home infusion) are acceptable for Commercial, Wisconsin ETF, Self-Funded and Exchange members (Exchange starting 1/1/2025).All care_continuum updates
- Prior AuthReimbursement/Payment PolicyNew mail order pharmacy options and formulary/quantity updates for MedicareDescribes addition of Froedtert Home Delivery (and mentions Cost Plus Drugs) as preferred mail order pharmacy options for Medicare members and summarizes multiple Medicare and commercial formulary, quantity limit, and prior authorization updates that affect pharmacy benefits and vaccine guidance.All care_continuum updates
- Prior AuthClinical/Medical PolicyPrior authorization criteria for TYENNE and ADEMPASDefines prior authorization requirements, clinical prerequisites, and coverage rules for TYENNE (162 mg/0.9 mL syringe and autoinjector) and ADEMPAS for Network Health members; affects prescribers, pharmacies, and utilization management staff reviewing PA requests.All care_continuum updates
- Prior AuthClinical/Medical PolicyPrior authorization criteria for TYENNE and ADEMPASDefines prior authorization requirements, clinical documentation, exclusions, age and prescriber restrictions, and coverage durations for TYENNE (162 mg/0.9 mL syringe/autoinjector) and ADEMPAS for Network Health Group Medicare Advantage Plans.All care_continuum updates
- Prior AuthClinical/Medical PolicyPrior authorization criteria for TYENNE and selected medicationsPrior authorization criteria for TYENNE (162 mg/0.9 mL syringe and autoinjector) and examples of other medications; covers requirements, prescriber and age restrictions, required documentation, exclusions, and prerequisite therapy for Care Continuum members.All care_continuum updates
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Tool Description
Search Care_continuumprior 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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