Clover_health Prior Authorization Lookup
Latest Clover_health prior authorization updates25
- Prior AuthClinical/Medical PolicyAmondys 45 (casimersen) Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Amondys 45, including initial and continuation treatment of Duchenne muscular dystrophy. Coverage applies when the member meets the genetic, functional, age, dosing, and response criteria described in the policy.All clover_health updates
- Prior AuthClinical/Medical PolicyBiCNU (carmustine) Coverage CriteriaPrior authorization for BiCNU (carmustine) under Clover Health Medicare Part B for specified FDA-approved and compendial oncology indications when approval criteria are met and applicable exclusions do not apply.All clover_health updates
- Prior AuthClinical/Medical PolicyBizengri (zenocutuzumab-zbco) Part B CoverageMedicare Part B coverage and prior authorization for Bizengri in adults with specified advanced, unresectable, metastatic, or recurrent NRG1 gene fusion-positive NSCLC or pancreatic adenocarcinoma.All clover_health updates
- Prior AuthClinical/Medical PolicyBlairex, Hyper-Sal, NebuSal, Pulmosal and Saline/Sodium Chloride Products for Nebulizer UseThis policy governs Medicare Part B coverage and prior authorization for saline/sodium chloride unit-dose and 500 mL or 1000 mL products used with nebulizers. Coverage is limited to dilution of covered concentrated nebulizer drugs or management of thick, tenacious pulmonary secretions associated with specified conditions when all approval criteria are met.All clover_health updates
- Prior AuthClinical/Medical PolicyBlenrep Coverage and Prior AuthorizationThis policy governs Medicare Part B coverage and prior authorization for Blenrep (belantamab mafodotin-blmf), including FDA-approved and specified compendial uses, for initial and continuation authorization requests.All clover_health updates
- Prior AuthClinical/Medical PolicyBortezomib (Velcade) Coverage CriteriaMedicare Part B coverage and prior authorization for bortezomib (Velcade) for specified hematologic malignancies and related conditions, subject to approval criteria and applicable exclusions.All clover_health updates
- Prior AuthClinical/Medical PolicyCasgevy Coverage for Sickle Cell DiseaseThis policy governs Medicare Part B coverage and prior authorization for Casgevy (exagamglogene autotemcel) in members with sickle cell disease. Coverage is limited to members meeting the specified age, genotype, vaso-occlusive episode, transplant eligibility, and prior-treatment criteria.All clover_health updates
- Prior AuthClinical/Medical PolicyColumvi (glofitamab-gxbm) Coverage CriteriaThis policy governs Medicare Part B prior authorization and continuation coverage for Columvi, including FDA-approved and specified compendial uses in adult patients with relapsed or refractory B-cell lymphomas. Coverage requires satisfaction of the applicable clinical criteria and absence of exclusions to therapy.All clover_health updates
- Prior AuthClinical/Medical PolicyDatroway (datopotamab deruxtecan-dlnk) Part B Coverage and Prior AuthorizationThis policy governs Medicare Part B coverage and authorization for Datroway, including FDA-approved and compendial oncology uses in adults with specified breast cancer or non-small cell lung cancer. Coverage requires the applicable clinical criteria, documentation, and continuation-of-therapy requirements to be met.All clover_health updates
- Prior AuthClinical/Medical PolicyElrexfio (elranatamab-bcmm) Coverage and Prior AuthorizationThis policy governs Medicare Part B coverage and authorization for Elrexfio (elranatamab-bcmm), including initial and continuation therapy. It applies to members receiving treatment for relapsed or refractory multiple myeloma and to providers submitting authorization requests.All clover_health updates
- Prior AuthClinical/Medical PolicyEnhertu and Trastuzumab Biologics Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Enhertu, trastuzumab, trastuzumab/hyaluronidase, and related trastuzumab biologics for breast, gastric, and gastroesophageal junction cancer in Florida, Puerto Rico, and the U.S. Virgin Islands.All clover_health updates
- Prior AuthClinical/Medical PolicyEylea, Eylea HD, and Aflibercept Biosimilars Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for Eylea, Eylea HD, and specified aflibercept biosimilars for ophthalmic conditions when documented coverage criteria are met.All clover_health updates
- Prior AuthClinical/Medical PolicyFibryga (fibrinogen [human]) Coverage and Prior AuthorizationThis policy governs Medicare Part B coverage and authorization for Fibryga, including brand and generic fibrinogen [human] products in all dosage forms and strengths unless otherwise stated. Coverage applies to specified congenital or acquired fibrinogen deficiencies when approval criteria are met and no exclusion applies.All clover_health updates
- Prior AuthClinical/Medical PolicyHerceptin Hylecta Coverage and Prior AuthorizationMedicare Part B coverage and authorization for Herceptin Hylecta in adults with HER2-positive breast cancer, including FDA-approved uses, specified compendial substitution for intravenous trastuzumab, and continuation when clinical benefit is demonstrated.All clover_health updates
- Prior AuthClinical/Medical PolicyIntramuscular Immune Globulin Coverage CriteriaThis policy governs Medicare Part B coverage and prior authorization for intramuscular immune globulin, including GamaSTAN, for specified infectious-disease exposures and immunoglobulin deficiency. Coverage applies in the listed jurisdiction states when approval criteria are met and the member has no exclusions to the prescribed therapy.All clover_health updates
- Prior AuthClinical/Medical PolicyIxempra (ixabepilone) Coverage CriteriaThis policy governs prior authorization for Ixempra in patients with breast cancer, including initiation and continuation requirements, disease characteristics, prior therapy, combination use, HER2 testing, treatment benefit, and hepatic laboratory parameters.All clover_health updates
- Prior AuthClinical/Medical PolicyJevtana (cabazitaxel) Coverage CriteriaThis policy governs Clover Health prior authorization criteria for Jevtana (cabazitaxel) in patients with metastatic castration-resistant prostate cancer. It applies to providers requesting initiation or continuation of therapy.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B AranespThis policy governs prior authorization and medical-necessity requirements for Aranesp (darbepoetin alfa) administered under Medicare Part B for qualifying chemotherapy-related, ESRD or CKD-related, and selected lower-risk MDS anemias.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B BeovuThis policy governs prior authorization and coverage of Beovu for Medicare Part B members in specified Medicare Administrative Contractor jurisdictions, including neovascular age-related macular degeneration and diabetic macular edema.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B Bisphosphonate Drug TherapyThis policy governs coverage and prior authorization for intravenous ibandronate sodium, pamidronate disodium, and zoledronic acid under Medicare Part B. It applies to Clover Health members in the specified Medicare jurisdictions when treatment is requested for listed covered indications and the applicable clinical criteria are met.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B CamceviThis policy governs prior authorization and coverage of Camcevi, including brand and generic products and all dosage forms and strengths, for Medicare Part B members in specified jurisdictions. Coverage applies to prostate cancer, certain salivary gland tumors, and other approvable indications when the stated approval criteria and applicable exclusions are satisfied.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B DaxxifyThis policy governs prior authorization and coverage of Daxxify under Medicare Part B for adults with cervical dystonia, subject to approval criteria and exclusions.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B DysportThis policy governs coverage and prior authorization for Dysport (abobotulinumtoxinA) under Medicare Part B for Clover Health members in Florida, Puerto Rico, and the U.S. Virgin Islands. It defines covered indications, age requirements, authorization duration, and exclusions.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B DysportClover Health Medicare Part B coverage and prior authorization for Dysport (abobotulinumtoxinA), including covered indications, clinical criteria, exclusions, and treatment frequency in Kentucky and Ohio.All clover_health updates
- Prior AuthClinical/Medical PolicyJurisdiction Specific Medicare Part B EligardThis policy governs prior authorization and coverage of Eligard under Medicare Part B for specified oncologic, gynecologic, and gender dysphoria indications in Medicare Administrative Contractor Jurisdictions 06 and K.All clover_health updates
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Tool Description
Search Clover_healthprior 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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