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 6/1/2025
Pharmacy Prior Authorization Grid | Effective 1/01/2025 - 5/31/2025
Behavioral Health Prior Authorization Grid | Effective 1/01/2025
Part B Step Therapy Guide | Effective 6/1/2025
Part B Step Therapy Guide | Effective 1/01/2025 - 5/31/2025
Medical Prior Authorization Grid | Effective 1/23/2025
Medical Prior Authorization Grid | Effective 1/01/2024 - 1/22/2025
Medical Prior Authorization Grid | Effective 1/01/2023 - 12/31/2023
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