Medical Policy UpdatesCoOportunity Health has Medical Policies that contain coverage criteria and guidelines that describe how we make coverage decisions for certain health care services and items. Please call our Member Services Department at 1.888.324.2064 if you have any questions.
The information presented regarding coverage criteria and guidelines is regularly updated and is subject to change without notice. Read more…
If unsure of the keyword spelling, enter the first three letters of the word followed by an asterisk (*). Example: enter acu* to locate the acupuncture policy.
Policy search filters
| Policy name | Policy category | Product | Prior authorization required |
|---|---|---|---|
| Abatacept (Orencia) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Abdominoplasty/panniculectomy | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Access to outpatient behavioral health services | Behavioral Health | CoOportunity Health Iowa Nebraska | Yes |
| Actigraphy | Medical Services Investigational | CoOportunity Health Iowa Nebraska | No |
| Actinic keratoses treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Acupuncture | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Ado-trastuzumab (Kadcyla®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Adoption | Other | CoOportunity Health Iowa Nebraska | No |
| Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (Remodulin® null), iloprost (Ventavis®) and sildenafil injection (Revatio®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Air compressor | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Air-fluidized specialty bed (group III) | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Airway clearance system/chest compression generator system | Equipment/Supplies | CoOportunity Health Iowa Nebraska | Yes |
| Alemtuzumab (Lemtrada™) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Allergy testing immunotherapy | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Allograft transplant for orthopedic procedures of the knee (e.g., DeNovo®NT) | Investigational Medical Services Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Alopecia areata treatment | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Alpha-1 antitrypsin (AAT) deficiency enzyme replacement therapy: Alpha-1 Proteinase Inhibitor (Aralast NP®, Glassia®, Prolastin®-C and Zemaira®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Ambu bag | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Ambulance & medical transportation | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
| Ankle replacement surgery | Surgery | CoOportunity Health Iowa Nebraska | Yes |
| Anti-nausea wristband | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Apheresis | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Apnea monitor | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Aqua K pad and pump | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Artificial insemination (AI) or intra-uterine insemination (IUI) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Artificial intervertebral disc replacement - cervical | Surgery Spine Medical Services | CoOportunity Health Iowa Nebraska | Yes |
| Artificial intervertebral disc replacement - lumbar | Investigational Spine | CoOportunity Health Iowa Nebraska | No |
| Asparaginase Erwinia chrysanthemi (Erwinaze®) | Pharmacy | CoOportunity Health Iowa Nebraska | Yes |
| Augmentative communication device | Equipment/Supplies | CoOportunity Health Iowa Nebraska | No |
| Autism services - Nebraska | Behavioral Health | CoOportunity Health Nebraska | Yes |
| Autologous bone marrow grafting (ABMG) for osteonecrosis | Surgery | CoOportunity Health Iowa Nebraska | No |
| Autologous chondrocyte implantation (ACI) | Medical Services | CoOportunity Health Iowa Nebraska | No |
| Autologus platelet rich plasma (PRP) injections | Medical Services Investigational | CoOportunity Health Iowa Nebraska | No |
| Autopsy | Ancillary Services | CoOportunity Health Iowa Nebraska | No |
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