Medical Mutual - Ohio Prior Authorization Lookup
Latest Medical Mutual - Ohio prior authorization updates25
- Prior AuthReimbursement/Payment PolicyEff. 2026-06-03Global prior authorization for medical drugs (Global PA)Defines Medical Mutual prior authorization requirements for new specialty drugs and drugs with significant safety/abuse concerns for Commercial and Medicare Advantage members, with submission/contact procedures and a drug-specific code list (partial).All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-21Camzyos (mavacamten) — Obstructive Hypertrophic Cardiomyopathy Coverage CriteriaDefines recommended prior authorization criteria, approval durations, prescribing clinician requirements, and conditions not recommended for approval for Camzyos (mavacamten) for adults with symptomatic obstructive hypertrophic cardiomyopathy.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-21Cholbam (cholic acid) recommended authorization criteriaGuidance for recommended prior authorization and coverage criteria for Cholbam (cholic acid) under the pharmacy benefit, including indications, required documentation, prescriber specialty, and approval durations. Applies to providers seeking coverage for members under medical mutual - ohio.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-21Inflammatory Conditions Care Value PolicyDefines Medical Mutual of Ohio's coverage and prior authorization expectations for multiple biologic and oral therapies used to treat inflammatory conditions (e.g., RA, PsA, psoriasis, IBD). Applies to providers seeking PA for the listed drugs under this payer.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-05-15Medical Drug Prior Authorization (Global PA) — Commercial & Medicare Advantage coverage criteriaDefines Medical Mutual's prior authorization requirements and contact/process details for medical-administered drugs (Commercial and Medicare Advantage), including specialty drugs and medications with safety or diversion concerns.All medical mutual - ohio updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-05-01CPT/HCPCS Prior Authorization Code List — Commercial & Medicare AdvantageLists CPT/HCPCS codes, prior authorization requirements, submission processes, and vendor-managed delegations for Commercial and Medicare Advantage plans administered by Medical Mutual - Ohio.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-16Fintepla (fenfluramide) — Recommended Authorization CriteriaDefines recommended prior authorization and coverage criteria for Fintepla (fenfluramide) for treatment of seizures in Dravet syndrome and Lennox-Gastaut syndrome in patients aged 2 years and older.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-16Isturisa (osilodrostat) prior authorization for Cushing's diseaseDefines recommended prior authorization criteria, documentation, and approval durations for Isturisa (osilodrostat) for adult patients with endogenous Cushing's syndrome/Cushing's disease when surgery is not an option or not curative. Affects prescribers and payers managing pharmacy benefit coverage.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-16Lupkynis (voclosporin) — Recommended Authorization CriteriaPrior authorization guidance for outpatient pharmacy coverage of Lupkynis (voclosporin) for adults with active lupus nephritis, including initial and continuation criteria, prescriber requirements, and conditions not recommended for approval.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-16Miebo (perfluorohexyloctane) — Coverage Criteria for Dry Eye DiseaseGuidance for prior authorization, clinical criteria, and coverage determination for Miebo ophthalmic solution for treatment of signs and symptoms of dry eye disease in adults; affects prescribers and pharmacy benefit adjudication.All medical mutual - ohio updates
- Prior AuthReimbursement/Payment PolicyEff. 2026-04-16Mycapssa (octreotide) delayed-release capsules coverageDefines prior authorization recommendation, coverage criteria, and approval durations for Mycapssa (oral octreotide) for treatment of acromegaly in adults who have responded to and tolerated injectable somatostatin analogs, for Medical Mutual - Ohio pharmacy benefit.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-19DuvyzatPolicy governing prior-authorization recommended pharmacy benefit coverage of Duvyzat (givinostat) for treatment of Duchenne muscular dystrophy (DMD) in patients aged 6 years and older, including initial and continuing therapy clinical criteria, approval durations, documentation and conditions not recommended for approval.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-19Eohilia (Budesonide oral suspension) — Coverage CriteriaThis policy governs prior authorization and coverage criteria for Eohilia (budesonide oral suspension) used to treat eosinophilic esophagitis (EoE) in patients, specifying indications, prescriber requirements, and approval durations for the payer's pharmacy benefit.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-19RuconestDefines prior authorization, medical necessity, dosing, approval durations, site-of-care management, documentation and waste reporting requirements for Ruconest when billed under the medical or pharmacy benefit for treatment of acute hereditary angioedema (HAE) attacks (types I and II).All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-19Kisqali (ribociclib) and Kisqali Femara Co-Pack coverageDefines prior authorization, clinical coverage criteria, and approval durations for Kisqali (ribociclib) alone or as a co-pack with letrozole for treating HR+, HER2- advanced or high-risk early breast cancer in adults; applies to Medical Mutual - Ohio pharmacy benefit reviews.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-19Narcolepsy Products Prior Authorization PolicyDefines prior authorization requirements for Wakix, sodium oxybate products (Xyrem, Xywav, Lumryz) for narcolepsy and related indications; applies to pharmacy benefit coverage decisions for members under Medical Mutual - Ohio.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-15Recommended Authorization Criteria — Addyi (flibanserin)Recommended prior authorization criteria for pharmacy coverage of Addyi (flibanserin) for treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD)/female sexual interest/arousal disorder (FSIAD). Applies to prescribers requesting coverage through Medical Mutual - Ohio.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-18Gaucher Disease Oral Agents (Cerdelga, miglustat, Zavesca, Yargesa)Defines recommended prior authorization and coverage criteria for the oral Gaucher disease agents Cerdelga (eliglustat) and miglustat (Zavesca, Yargesa, generics) for adults with Type I Gaucher disease; applies to pharmacy benefit coverage determinations by the payer.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-18InPen Smart Insulin PenRecommended prior authorization criteria for coverage of the InPen smart insulin pen system (reusable Bluetooth-enabled pen plus app) for members using compatible U-100 rapid-acting insulins. Applies to payer coverage determinations for Medical Mutual - Ohio.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-18Litfulo (ritlecitinib) — prior authorization for alopecia areataPrior authorization guidance for pharmacy benefit coverage of Litfulo (ritlecitinib) for treatment of alopecia areata in patients aged 12 years and older; describes approval criteria, durations, and conditions not recommended for approval.All medical mutual - ohio updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-12-18Recommended Authorization Criteria — Egrifta (tesamorelin)Recommended prior authorization criteria for coverage of Egrifta (tesamorelin) for reduction of excess abdominal fat in adults with HIV-associated lipodystrophy; applies to pharmacy benefit coverage determinations by Medical Mutual - Ohio.All medical mutual - ohio updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-11-20Dawnzera (donidalorsen) coverage and prior authorizationGoverns prior authorization, coverage criteria, dosing, duration, and site-of-care restrictions for Dawnzera (donidalorsen) for prevention of hereditary angioedema (HAE) for applicable Medical Mutual - Ohio members.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-20Dawnzera (donidalorsen) — prophylaxis of hereditary angioedema (HAE)This policy governs prior-authorization, coverage criteria, dosing, and administrative requirements for Dawnzera (donidalorsen) used as prophylaxis of hereditary angioedema (HAE) for patients age ≥12, for Medical Mutual - Ohio members when billed under the medical or pharmacy benefit.All medical mutual - ohio updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-20Ledipasvir/sofosbuvir (Harvoni) — Coverage and DosingMedical Mutual - Ohio policy governing prior authorization, dosing, and coverage criteria for ledipasvir/sofosbuvir (Harvoni and authorized generics) for treatment of chronic hepatitis C virus (HCV) in pediatric and adult patients.All medical mutual - ohio updates
- Prior AuthReimbursement/Payment PolicyEff. 2025-11-20Recommended authorization criteria for Eliquis (apixaban) productsRecommended authorization criteria for pharmacy benefit coverage of Eliquis (apixaban) products, including tablets, tablets for oral suspension, and Eliquis Sprinkle; applies to requests for coverage and prior authorization determinations by Medical Mutual - Ohio.All medical mutual - ohio updates
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Tool Description
Search Medical Mutual - Ohioprior 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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