2026 Prior Authorization Grids

Behavioral Health

Applies to: B - UFC/ACC, B - UFC/ALTCS

• Behavioral Health Prior Authorization Grid | Effective 01/01/2026

Medical

Applies to: Banner Medicare Advantage Dual HMO D-SNP, Banner Medicare Advantage Prime HMO

• Medical Prior Authorization Grid | Effective 01/01/2026

Applies to: B - UFC/ACC, B - UFC/ALTCS

• Medical Prior Authorization Grid | Effective 01/01/2026 

Pharmacy

Applies to: B - UFC/ACC, B - UFC/ALTCS

• Pharmacy Prior Authorization Grid | Effective 01/1/2026 - 06/16/2026
• Pharmacy Prior Authorization Grid | Effective 06/17/2026

ALTCS Services

Applies to: B - UFC/ALTCS

• ALTCS Services Prior Authorization Grid | Effective 05/01/2026