QualChoice Prior Authorization Lookup
Latest QualChoice prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Abaloparatide (Tymlos) coverageDefines medical necessity and prior authorization criteria for abaloparatide (Tymlos) for treatment of osteoporosis in postmenopausal women and men at high fracture risk, and continuation criteria for members under QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Clinical Policy: Tradipitant (Nereus)Defines medical necessity and prior authorization criteria for coverage of tradipitant (Nereus) for prevention of motion-induced vomiting in adults across QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Difamilast (Adquey) topical for atopic dermatitisDefines medical necessity, prior authorization, and coverage criteria for topical difamilast (Adquey) for members age 2 and older across QualChoice lines of business (Commercial, HIM/ICHRA, Medicaid). Affects providers requesting coverage or continuation of Adquey.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Insulin icodec-abae (Awiqli) coverage criteriaDefines medical necessity, prior authorization, and coverage criteria for Awiqli (insulin icodec-abae) for adults with type 2 diabetes mellitus under QualChoice HIM/ICHRA lines of business; applies to providers requesting coverage and prior authorization.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Relacorilant (Lifyorli) coverage for platinum‑resistant ovarian, fallopian tube, or primary peritoneal cancerThis policy defines medical necessity and prior authorization criteria for relacorilant (Lifyorli) when used in combination with nab‑paclitaxel for adults with platinum‑resistant epithelial ovarian, fallopian tube, or primary peritoneal cancer, and provides continuation, dosing, contraindication, and related guidance affecting commercial, HIM/ICHRA, and Medicaid lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Sibeprenlimab-szsi (Voyxact) for IgA NephropathyPolicy governing prior authorization, medical necessity criteria, and coverage for Voyxact (sibeprenlimab-szsi) to reduce proteinuria in adults with primary IgA nephropathy for members of QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Aficamten (Myqorzo) coverageDefines medical necessity and prior authorization criteria for Aficamten (Myqorzo) for adults with symptomatic obstructive hypertrophic cardiomyopathy across QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Clinical Policy: Depemokimab-ulaa (Exdensur)Defines medical necessity, prior authorization, and coverage criteria for Exdensur (depemokimab-ulaa) as add-on maintenance treatment of severe eosinophilic asthma for eligible members; applies to QualChoice HIM line of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Clinical Policy: Lerodalcibep-liga (Lerochol)This policy defines medical necessity and prior authorization criteria for lerodalcibep-liga (Lerochol) for adults with hypercholesterolemia including heterozygous familial hypercholesterolemia (HeFH) across QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Duplicate TherapyThis policy governs pharmacy-level duplicate therapy edits that limit members from receiving multiple medications within the same or similar drug classes and defines prior authorization and documentation requirements for overrides; it applies to QualChoice Commercial membership unless state Medicaid overrides apply as noted.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Elinzanetant (Lynkuet) coverageDefines medical necessity and prior authorization criteria for elinzanetant (Lynkuet) for treatment of moderate to severe vasomotor symptoms due to menopause for QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Sevabertinib (Hyrnuo) coverageDefines clinical coverage, prior authorization criteria, and administration/dosing guidance for sevabertinib (Hyrnuo) for qualifying members across commercial, HIM, and Medicaid lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-03-01Ziftomenib (Komzifti) coverageDefines medical necessity and prior authorization criteria for ziftomenib (Komzifti) for treatment of adult patients with relapsed or refractory NPM1‑mutated acute myeloid leukemia across QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-27Navepegritide (Yuviwel) — Coverage Criteria for AchondroplasiaDefines medical necessity and prior authorization requirements for navepegritide (Yuviwel) for pediatric achondroplasia across applicable QualChoice lines of business (Commercial, ICHRA/HIM, Medicaid). Affects providers requesting coverage for initiation and continuation of therapy.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2026-01-01Clinical Policy: Age Limit OverrideGoverns medical necessity review and approval criteria when a member's age exceeds a health plan-approved formulary age limit for a drug that does not otherwise require prior authorization. Affects providers submitting requests for age limit overrides under the QualChoice (Centene-affiliated) health plans.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-12-01Abrocitinib (Cibinqo) — Coverage Criteria for Atopic DermatitisDefines medical necessity criteria, dosing limits, and prior authorization requirements for abrocitinib (Cibinqo) for commercial and HIM lines of business for patients age ≥12 with moderate-to-severe atopic dermatitis.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-18Plozasiran (Redemplo) — coverage criteria for familial chylomicronemia syndromeThis policy governs medical necessity criteria, prior authorization, and coverage for plozasiran (Redemplo) as adjunct to diet to reduce triglycerides in adults with familial chylomicronemia syndrome (FCS) for QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-11-03Doxecitine and Doxribtimine (Kygevvi) Coverage CriteriaDefines medical necessity and prior authorization criteria for Kygevvi for treatment of thymidine kinase 2 deficiency (TK2d) across applicable QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-19Elamipretide (Forzinity) coverage for Barth syndromeDefines medical necessity and prior authorization criteria for Forzinity (elamipretide) for members, primarily for treatment of Barth syndrome in eligible patients and guidance for other/off-label uses referencing related policies. Affects commercial, HIM, and Medicaid lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-12Cosmetic and Reconstructive ProceduresDefines medical necessity criteria, exclusions, and coding guidance for cosmetic and reconstructive surgical procedures for QualChoice members; affects providers submitting claims and requests for prior authorization.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-21Donidalorsen (Dawnzera) for hereditary angioedema prophylaxisCovers medical necessity and prior authorization criteria for donidalorsen (Dawnzera) used for prevention of hereditary angioedema (HAE) attacks in members age 12 and older across specified QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-08-14Zopapogene imadenovec-drba (Papzimeos) therapy for recurrent respiratory papillomatosisDefines medical necessity, prior authorization, and coverage criteria for Zopapogene imadenovec-drba (Papzimeos) for adults with recurrent respiratory papillomatosis (RRP) across QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-28Sepiapterin (Sephience) coverageDefines medical necessity and prior authorization criteria for Sephience (sepiapterin) for treatment of hyperphenylalaninemia (HPA) due to sepiapterin‑responsive phenylketonuria (PKU) across applicable QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-03Sebetralstat (Ekterly) — Coverage CriteriaDefines medical necessity and prior authorization criteria for Ekterly (sebetralstat) when used to treat acute hereditary angioedema (HAE) in patients age 12 and older for QualChoice lines of business.All QualChoice updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-16Garadacimab-gxii (Andembry) — prophylaxis for hereditary angioedemaPolicy governing medical necessity and prior authorization criteria for Andembry (garadacimab-gxii) as prophylaxis to prevent hereditary angioedema (HAE) attacks across applicable QualChoice lines of business.All QualChoice updates
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Tool Description
Search QualChoiceprior 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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