Community-Care Prior Authorization Lookup
Latest Community-Care prior authorization updates16
- Prior AuthAdministrative/Operational PolicyAuthorization Request / Prior Authorization SubmissionThis document governs submission of prior authorization requests to CommunityCare’s Medical Management, including required clinical information and contact/fax details; it affects ordering providers and servicing facilities seeking authorization for patient services.All Community-Care updates
- Prior AuthClinical/Medical PolicyAuthorization Request / Prior Authorization Submission RequirementsThis document governs the requirements for submitting prior authorization requests to CommunityCare Medical Management and describes what information must accompany requests to determine medical necessity. It applies to providers requesting authorization for services for CommunityCare members in North Carolina.All Community-Care updates
- Prior AuthClinical/Medical PolicyBotulinum toxin products — medical coverage criteriaDefines coverage, prior authorization, quantity limits, and continuation criteria for botulinum toxin products (preferred: Botox, Dysport, Xeomin) across neurologic and related indications for Community-Care members in North Carolina.All Community-Care updates
- Prior AuthClinical/Medical PolicyCommunityCare ACA Formulary / Drug List (partial)Defines which prescription drugs are covered under the CommunityCare ACA formulary and explains member requirements, pharmacy network use, and common utilization controls (prior authorization, quantity limits, step therapy). Applies to members of CommunityCare ACA Individual Silver, Gold, and Expanded Bronze Standardized Plans.All Community-Care updates
- Prior AuthClinical/Medical PolicyCommunityCare ACA Prescription Drug Formulary (partial) - Coverage CriteriaDescribes CommunityCare ACA prescription drug list structure, member obligations to use network pharmacies, formulary rules (prior authorization, step therapy, quantity limits), tiers and copay structure, and examples affecting CommunityCare ACA members and their prescribing providers/pharmacies.All Community-Care updates
- Prior AuthClinical/Medical PolicyDelandistrogene moxeparvovec (Elevidys) — Coverage Criteria for Duchenne muscular dystrophyThis medical benefit medication utilization policy defines coverage criteria, quantity limits, and authorization period for delandistrogene moxeparvovec (Elevidys) for members with Duchenne muscular dystrophy (DMD). It applies to providers seeking prior authorization for this therapy.All Community-Care updates
- Prior AuthClinical/Medical PolicyFormulary Exception / Prior Authorization Request FormDescribes the process and required information for requesting formulary exceptions, prior authorizations, quantity limit overrides, or step therapy determinations for CommunityCare members; applies to members, prescribers, and designated representatives seeking access to clinically appropriate drugs.All Community-Care updates
- Prior AuthClinical/Medical PolicyFormulary Exception / Prior Authorization Request FormDefines the process and required information for requesting a formulary exception, prior authorization, quantity limit override, or step therapy determination from CVS Caremark on behalf of CommunityCare members; applies to members, prescribers, or authorized designees seeking access to clinically appropriate drugs.All Community-Care updates
- Prior AuthClinical/Medical PolicyFormulary Exception / Prior Authorization Request FormGoverns submission and processing of requests for formulary exceptions, prior authorizations, quantity limit overrides, and step therapy determinations for CommunityCare members; applies to members, prescribers, and authorized representatives seeking coverage for pharmacy drugs.All Community-Care updates
- Prior AuthClinical/Medical PolicyFormulary Exception / Prior Authorization Request FormThis document governs requests for formulary exceptions, prior authorizations, step therapy overrides, and quantity limit exceedances for CommunityCare members; it applies to members, their designees, and prescribing providers seeking access to medications not routinely covered or subject to utilization management. It also outlines required information and processing timeframe.All Community-Care updates
- Prior AuthClinical/Medical PolicyIntravenous ustekinumab (all brands) — Medical Benefit Medication Utilization PolicyThis medical benefit medication utilization policy governs prior authorization and coverage criteria for intravenous ustekinumab products (originator and biosimilars) for Crohn's disease and ulcerative colitis for Community-Care members.All Community-Care updates
- Prior AuthClinical/Medical PolicyLamzede (velmanase alfa) Medical Benefit Medication Utilization PolicyDefines medical benefit coverage criteria, authorization, and coding guidance for velmanase alfa (Lamzede) for treatment of alpha-mannosidosis; applies to providers requesting prior authorization from the payer for affected members.All Community-Care updates
- Prior AuthClinical/Medical PolicyPombiliti (cipaglucosidase alfa) Medical Benefit Medication Utilization PolicyDefines medical-benefit coverage, prior authorization, quantity limits, and continuation criteria for cipaglucosidase alfa (Pombiliti) used to treat late-onset Pompe disease for members covered by the payer.All Community-Care updates
- Prior AuthClinical/Medical PolicySenior Health Plan 2026 Formulary — Part D Coverage CriteriaDefines the prescription drugs covered, coverage rules (prior authorization, step therapy, quantity limits), and cost-sharing tiers for Senior Health Plan members of Platinum, Platinum Plus, Silver Plus, and Oklahoma Dual Complete. Applies to plan members and network pharmacies using the 2026 formulary table.All Community-Care updates
- Prior AuthClinical/Medical PolicySenior Health Plan Part D Formulary (abridged) — Prescription Drug Coverage CriteriaDefines the plan's prescription drug formulary, coverage rules (prior authorization, step therapy, quantity limits), and cost-sharing for Senior Health Plan members (Medicare Advantage plans listed) and network pharmacy use.All Community-Care updates
- Prior AuthClinical/Medical PolicyUplizna (inebilizumab) Medical Benefit Medication Utilization PolicyDefines medical necessity criteria, quantity limits, authorization periods, and coding for inebilizumab (Uplizna) when administered as a medical benefit for specific indications; applies to providers seeking prior authorization from the payer for patients in North Carolina.All Community-Care updates
1–16 of 16
1 / 1
Tool Description
Search Community-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.
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.