Internal Coverage Criteria for Medicare Part B Drugs

When reviewing a prior authorization request, Devoted Health uses InterQual™ clinical criteria for the services and procedures listed in this policy: Services reviewed using InterQual criteria (PDF)

See InterQual’s detailed coverage criteria. (Note: you'll need to create an Optum One Healthcare ID account to access the criteria.)

Learn about InterQual’s development process (PDF)

For cases when coverage criteria are not fully spelled out in these resources, we created internal coverage criteria based on current evidence in widely used treatment guidelines or in publicly available clinical literature.

Drugs without Step Therapy

Cabenuva (cabotegravir/rilpivirine) Coverage Policy

Corticosteroid Intravitreal Implant Coverage Policy

Durysta (bimatoprost intracameral implant) Coverage Policy

Glucose Monitors and Supplies Coverage Policy

Ilaris®️ (canakinumab) Coverage Policy

Korsuva Coverage Policy

Krystexxa (pegloticase) Coverage Policy

Leqembi (lecanemab-irmb) Coverage Policy

Leqvio (inclisiran) Coverage Policy

Outpatient Infusion of Insulin Tech Assessment

Syfovre®️ (pegcetacoplan) Coverage Policy

Tepezza (teprotumumab-trbw) Coverage Policy

Vyepti®️ (eptinezumab) Coverage Policy

Vyvgart (efgartigimod alfa) Coverage Policy

Xiaflex (collagenase clostridium histolyticum) Coverage Policy

Zynteglo (betibeglogene autotemcel) Coverage Policy

Drugs with Step Therapy

Acromegaly Step Therapy Coverage Criteria

Alpha1-Proteinase Inhibitors Step Therapy Coverage Criteria

Bevacizumab for Oncology Use Step Therapy Coverage Criteria

Botulinum Toxin Step Therapy Coverage Criteria

Complement Inhibitor Step Therapy Coverage Criteria

Disease-Modifying Antirheumatic Drug Products Step Therapy Coverage Criteria

Erythropoiesis Stimulating Agent Step Therapy Coverage Criteria

Gaucher Disease Step Therapy Coverage Criteria

GNRH For Use in Prostate Cancer Step Therapy Coverage Criteria

Hemophilia Factor VIII Products Step Therapy Coverage Policy

Hemophilia Factor IX Products Step Therapy Coverage Policy

Hypercalcemia of Malignancy Step-Therapy Coverage Policy

Immune Globulin Step Therapy Coverage Policy

Infliximab Step Therapy Coverage Criteria

IV Iron Coverage Policy

Long Acting Colony Stimulating Factor Step Therapy Coverage Criteria

Mitotic Inhibitors Step Therapy Coverage Policy

Multiple Sclerosis Step Therapy Coverage Criteria

Osteoporosis Coverage Policy

Pemetrexed Product Step Therapy Coverage Policy

Pertuzumab Product Step Therapy Coverage Policy

Rituximab Product Step Therapy Coverage Criteria

Severe Asthma Step Therapy Coverage Criteria

Short Acting Colony Stimulating Factor Step Therapy Coverage Criteria

Trastuzumab Product Step Therapy Coverage Criteria

VEGF for Ophthalmic Use Step Therapy Coverage Criteria

Viscosupplement Step Therapy Coverage Policy