The Prior Authorization Grids are your source for determining what medications and services require Prior Authorization. Be sure to reference the date of the grid since revisions to the grid may occur.
Pharmacy Prior Authorization Grid | Effective 5/15/2024
Pharmacy Prior Authorization Grid | Effective 1/1/2024
Behavioral Health Prior Authorization Grid | Effective 4/1/2022
Part B Step Therapy Guide | Effective 1/1/2024
Medical Prior Authorization Grid | Effective 1/01/2024
Medical Prior Authorization Grid | Effective 1/01/2023 - 12/31/2023
Medical Prior Authorization Grid | Effective 4/01/2024 - 12/31/2022
Medical Prior Authorization Grid | Effective 1/01/2022 - 03/31/2022
Internal Pharmacy Prior Authorization Criteria | Effective 12/1/2023