Washington State Health Care Authority Prior Authorization Lookup
- Washington State Health Care Authority coverage criteria
- All Washington State Health Care Authority policy updates
Latest Washington State Health Care Authority prior authorization updates25
- Prior AuthClinical/Medical PolicyEff. 2026-10-01Asthma and COPD Agents: Monoclonal AntibodiesWashington Apple Health fee-for-service coverage and prior authorization for monoclonal antibody drugs used for asthma, eosinophilic COPD, EGPA, hypereosinophilic syndrome, chronic rhinosinusitis with nasal polyps, chronic spontaneous urticaria, and IgE-mediated food allergy.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-01MethadoneWashington State Health Care Authority Medicaid fee-for-service coverage and prior authorization requirements for methadone products, including clinical criteria, dose and quantity limits, documentation, billing codes, and approval durations.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Oncology Agents: Antimetabolites - OralThis policy governs prior authorization and medical necessity review for oral antimetabolite agents used for acute myeloid leukemia in Apple Health Medicaid fee-for-service, including azacitidine (Onureg) and thioguanine (Tabloid).All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-08-01Transmucosal Fentanyl ProductsPrior authorization and medical necessity criteria for transmucosal fentanyl products used to treat breakthrough cancer pain in patients receiving around-the-clock opioid therapy for persistent cancer pain through Washington State Health Care Authority Apple Health fee-for-service.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-07-01Antidiabetics - GLP-1 AgonistsThis policy governs prior authorization and medical-necessity coverage for GLP-1 agonists used primarily to treat type 2 diabetes, including specified criteria for tirzepatide in adults with obesity and moderate-to-severe obstructive sleep apnea. It applies to providers requesting coverage through Washington State Health Care Authority Apple Health.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Immune Modulators - Thalidomide AnalogsMedicaid fee-for-service coverage and prior authorization for lenalidomide, pomalidomide, and thalidomide for specified oncology and non-oncology indications, including medical-necessity criteria, reauthorization, preferred-drug requirements, and dosage and quantity limits.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-06-01Movement Disorder Agents: Valbenazine (Ingrezza)Prior authorization and medical-necessity coverage for valbenazine (Ingrezza) to treat Huntington disease chorea and tardive dyskinesia in Apple Health members, including clinical criteria, reauthorization, prescriber qualifications, exclusions, step therapy, and quantity limits.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Adenosine Triphosphate-Citrate Lyase InhibitorsApple Health fee-for-service prior authorization for Nexletol and Nexlizet in adults with cardiovascular risk or primary hyperlipidemia, including heterozygous familial hypercholesterolemia.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Cardiovascular Agents - Vasoactive Soluble Guanylate Cyclase StimulatorsPrior authorization and medical necessity coverage for vericiguat (Verquvo) for Apple Health members, including preferred-drug requirements, clinical eligibility, reauthorization, and quantity limits.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-04-01Cytokine and CAM Antagonists: T-Lymphocyte Inhibitors — Abatacept (Orencia)Washington Apple Health coverage and prior authorization for abatacept for polyarticular juvenile idiopathic arthritis, psoriatic arthritis, rheumatoid arthritis, and graft-versus-host disease.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists — Wegovy (semaglutide)This policy governs Apple Health coverage and prior authorization for Wegovy semaglutide injection and tablet formulations for adults with established cardiovascular disease and overweight or obesity or with moderate-to-severe noncirrhotic MASH. It establishes medical-necessity criteria, reauthorization requirements, dosage limits, and an exclusion for weight-loss use.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Cytokine and CAM Antagonists: IL-36 InhibitorsPrior authorization and medical-necessity coverage for spesolimab-sbzo (Spevigo) for generalized pustular psoriasis under Washington Apple Health.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2026-02-01Vasopressin Receptor Antagonists - OralThis policy governs Washington Apple Health prior authorization and medical-necessity coverage for oral tolvaptan products used for autosomal dominant polycystic kidney disease and hypervolemic or euvolemic hyponatremia. It applies to providers requesting coverage for generic tolvaptan, Jynarque, or Samsca.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Granulocyte Colony Stimulating Factors (G-CSF)This policy governs prior authorization and medical-necessity coverage for filgrastim, pegfilgrastim, eflapegrastim-xnst, tbo-filgrastim, and their biosimilars for Apple Health members. It establishes preferred-drug sequencing, covered indications, clinical approval criteria, exclusions, dosage and quantity limits, and applicable HCPCS billing codes.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-10-01Rifaximin (Xifaxan®)This policy governs Washington Apple Health coverage and prior authorization requirements for oral rifaximin used for hepatic encephalopathy prophylaxis, IBS-D, and infectious/traveler’s diarrhea caused by noninvasive E. coli.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-09-01Cystic Fibrosis Agents (Oral)This policy governs prior authorization and medical necessity for oral CFTR modulators used to treat cystic fibrosis under Washington Apple Health. It applies to providers requesting initial approval, transition therapy, or reauthorization for eligible Apple Health members.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Brands with Biosimilars or A-rated GenericsThis general pharmacy program policy governs prior authorization for brand-name products when an A-rated generic, biosimilar, or interchangeable biosimilar is available. It applies to requests for non-preferred brand products and requires trials of available preferred alternatives unless a documented unique clinical circumstance supports an exception.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Cytokine and CAM Antagonists: Integrin Receptor AntagonistsThis policy governs prior authorization and medical-necessity coverage for vedolizumab (Entyvio and Entyvio Pen) for adults with moderate-to-severe Crohn’s disease or ulcerative colitis, including clinical criteria, preferred-drug step therapy, reauthorization, quantity limits, and billing coding.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Cytokine and CAM Antagonists: S1-P Receptor ModulatorsThis policy governs prior authorization and medical-necessity coverage for etrasimod (Velsipity) for adults with moderate-to-severe ulcerative colitis, including authorization criteria, reauthorization, preferred-drug trials, dosing limits, and documentation requirements.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Multiple Sclerosis Agents: Ozanimod (Zeposia)This policy governs Washington Apple Health fee-for-service prior authorization and medical-necessity review for ozanimod (Zeposia) in adults with qualifying multiple sclerosis or moderate-to-severe ulcerative colitis. It specifies clinical eligibility, preferred-drug trials, reauthorization, and quantity limits.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-07-01Multiple Sclerosis Agents: natalizumab (Tysabri)Apple Health Medicaid fee-for-service prior authorization, medical-necessity review, dosing limits, and reauthorization for natalizumab (Tysabri) in eligible adults with multiple sclerosis, clinically isolated syndrome, or moderate-to-severe Crohn's disease.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-01Bone Density Regulators - CalcitoninsWashington Apple Health coverage and prior authorization for calcitonin-salmon products used for hypercalcemia, Paget's disease, and postmenopausal osteoporosis, including clinical criteria, preferred-drug trials, reauthorization, dosage, and quantity limits.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-06-01Bone Density Regulators - RANKL InhibitorsThis policy governs Washington Apple Health fee-for-service prior authorization and medical-necessity review for the RANKL inhibitors denosumab (Prolia and Xgeva). It establishes indication-specific clinical criteria, preferred-drug step therapy, reauthorization requirements, dosing limits, and billing information.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2025-05-01Anorexiants/Anti-Obesity: GLP-1 Receptor Agonists Zepbound® (tirzepatide)Washington Apple Health coverage and prior authorization requirements for Zepbound (tirzepatide) in adults with obesity and moderate to severe obstructive sleep apnea, including initial authorization, reauthorization, preferred-drug sequencing, documentation, and dosage requirements.All Washington State Health Care Authority updates
- Prior AuthClinical/Medical PolicyEff. 2024-10-01Antihemophilic Products - Etranacogene dezaparvovec-drlb (Hemgenix)This policy governs Apple Health coverage and prior authorization for etranacogene dezaparvovec-drlb (Hemgenix), a single-dose gene therapy for adults with moderately severe or severe congenital Factor IX deficiency (hemophilia B).All Washington State Health Care Authority updates
1–25 of 68
1 / 3
Tool Description
Search Washington State Health Care Authorityprior 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.
- Billing Code Reimbursement RatesBuild a reimbursement rate report across any mix of billing codes and states, comparing commercial payers against Medicare.
- Payer Comparison DashboardPick 2-5 payers to compare market share, premium, and membership by region, all at once.
- Facility Comparison DashboardPick 2-6 hospital facility types (or add a specific hospital) to compare facility count, revenue, net income, and Medicare/Medicaid payer mix by region, all at once.
- 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.