| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth under conditions | FEP Blue Focus only | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth required | | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Virginia), effective Q1 2022 |
| Molina Complete Care (Virginia) | Medicaid | VA | prior auth required | | Apr 1, 2025 | Virginia Medicaid PA Code Matrix and Virginia code/benefit exceptions, effective Q2 2025 |
| Molina Healthcare of Arizona | Medicare-only PA matrix for D-SNP | AZ | prior auth required | | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 |
| Molina Healthcare of California | Medicaid | CA | prior auth required | | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 |
| Molina Healthcare of California | Medicare Advantage | CA | prior auth required | | Jul 1, 2021 | Medicare Prior Auth (PA) Code Matrix (California), effective Q3 2021 |
| Molina Healthcare of Florida | Medicare Advantage | FL | prior auth required | | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Florida), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicare Advantage | ID | prior auth required | | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Idaho), effective Q2 2021 |
| Molina Healthcare of Idaho | Medicaid | ID | prior auth required | | Jan 1, 2025 | Idaho Medicaid Prior Auth (PA) Code Matrix and Idaho code/benefit exceptions, Q1 2025 |
| Molina Healthcare of Illinois | Medicaid | IL | prior auth required | | Jan 1, 2022 | Molina Healthcare of Illinois Codification Grid Q3 2026 |
| Molina Healthcare of Iowa | Medicaid | IA | prior auth required | | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| Molina Healthcare of Michigan | Medicare Advantage | MI | prior auth required | | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth required | | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Michigan | Exchange | MI | prior auth required | | Jul 1, 2021 | Molina Healthcare of Michigan PA Matrix, effective 7/1/2021 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | | Oct 1, 2022 | Medicaid Prior Auth (PA) Code Matrix, effective Q4 2022 |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth required | | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 |
| Molina Healthcare of New Mexico | Medicare Advantage | NM | prior auth required | | Jan 1, 2021 | Medicare Prior Auth (PA) Code Matrix (New Mexico), effective Q1 2021 |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth required | | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Medicare and MyCare Ohio (MMP) Medicare | OH | prior auth required | | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Exchange | OH | prior auth required | | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of South Carolina | Medicare Advantage | SC | prior auth required | | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (South Carolina), effective Q2 2021 |
| Molina Healthcare of Texas | STAR | TX | prior auth required | | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR), reviewed 2025-02-19 |
| Molina Healthcare of Texas | STAR+PLUS | TX | prior auth required | | Feb 19, 2025 | Molina Healthcare of Texas Prior Authorization Annual Review Report (STAR+PLUS), reviewed 2025-02-19 |
| Molina Healthcare of Texas | STAR, STAR+PLUS, STAR Kids, CHIP (Medicaid PA code matrix) | TX | prior auth required | | Jul 1, 2026 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| Molina Healthcare of Utah | Medicaid | UT | prior auth required | | Jan 1, 2025 | Utah Medicaid Prior Auth (PA) Code Matrix and Utah code/benefit exceptions, Q1 2025 |
| Molina Healthcare of Utah | Medicare Advantage | UT | prior auth required | | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Utah), effective Q2 2021 |
| Molina Healthcare of Washington | Medicare Advantage | WA | prior auth required | | Apr 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Washington), effective Q2 2021 |
| Molina Healthcare of Wisconsin | Medicare Advantage | WI | prior auth required | | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 |
| Molina Healthcare, Inc. (national grid) | Molina national (MHI) Medicare grid | All | prior auth required | | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (national), effective Q4 2021 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth required | | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| Neighborhood Health Partnership | Neighborhood Health Partnership | FL | prior auth required | | Sep 1, 2026 | Prior authorization requirements for Neighborhood Health Partnership Effective September 1, 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ | CO | prior auth required | | Oct 1, 2026 | Rocky Mountain Children’s Health Plan - prior authorization Effective October 1, 2026 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth required | | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Complete (Individual & Family plans) | All | prior auth required | | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Complete Effective September 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP) | All | prior auth required | Excluded plans: Erickson Advantage | Oct 1, 2026 | UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026 |
| UnitedHealthcare Community Plan | AHCCCS Complete Care (ACC) | AZ | prior auth required | | Oct 1, 2026 | Prior authorization requirements for AHCCCS Complete Care (ACC) Medicaid effective October 1, 2026 |
| UnitedHealthcare Community Plan | ALTCS Developmentally Disabled | AZ | prior auth required | | Oct 1, 2026 | Prior authorization requirements for Arizona Developmental Disabilities Effective October 1, 2026 |
| UnitedHealthcare Community Plan | ALTCS Long Term Care | AZ | prior auth required | | Oct 1, 2026 | Prior authorization requirements for Arizona Long Term Care Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Louisiana Medicaid (Healthy Louisiana) | LA | prior auth required | | Jan 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Louisiana |
| UnitedHealthcare Community Plan | Maryland HealthChoice | MD | prior auth required | | Sep 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Maryland Effective September 1, 2026 |
| UnitedHealthcare Community Plan | Massachusetts OneCare | MA | prior auth required | | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) | MA | prior auth required | | Nov 1, 2025 | CPT® is a registered trademark of the American Medical Association. Prior authorization requirements for Massachusetts Senior Care Options Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Minnesota Metro Medicaid | MN | prior auth required | | Oct 1, 2024 | Prior authorization requirements for Minnesota Medicaid Effective October 1, 2024 |
| UnitedHealthcare Community Plan | Mississippi CHIP | MS | prior auth required | | Apr 1, 2025 | Prior authorization requirements for Mississippi Children’s Health Insurance Program Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | MississippiCAN | MS | prior auth required | | Apr 1, 2025 | Prior authorization requirements for UnitedHealthcare Community Plan of Mississippi – Mississippi Coordinated Access Network (MississippiCAN) Effective Apr. 1, 2025 |
| UnitedHealthcare Community Plan | Missouri Medicaid | MO | prior auth required | | Jul 1, 2026 | Prior authorization requirements for Missouri Medicaid Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Nebraska Heritage Health | NE | prior auth required | | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Nebraska Effective July 1, 2026 General Information This list contains prior authorization requirements for participating United |
| UnitedHealthcare Community Plan | New Mexico Turquoise Care | NM | prior auth required | | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New Mexico Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Ohio Medicaid | OH | prior auth required | | Nov 1, 2025 | Prior authorization requirements for Ohio Medicaid Effective November 1, 2025 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community Plan |
| UnitedHealthcare Community Plan | Pennsylvania CHIP | PA | prior auth required | | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania CHIP Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Pennsylvania Medicaid | PA | prior auth required | | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Pennsylvania Effective July 1, 2026 |
| UnitedHealthcare Community Plan | Rhode Island Medicaid | RI | prior auth required | | May 1, 2026 | Prior authorization requirements for Rhode Island Medicaid Effective May 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan of Rhode Island h |
| UnitedHealthcare Community Plan | TennCare | TN | prior auth required | | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Tennessee Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth required | site of care: site of service reviewed | Jan 1, 2015 | Prior authorization requirements for Texas CHIP Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan Texas CHIP health care |
| UnitedHealthcare Community Plan | Texas STAR | TX | prior auth required | site of care: site of service reviewed | Jan 1, 2015 | Prior authorization requirements for Texas STAR Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR h |
| UnitedHealthcare Community Plan | Texas STAR Kids | TX | prior auth required | site of care: site of service reviewed | Nov 1, 2016 | Prior authorization requirements for STAR Kids Effective September 1, 2026 This list contains prior authorization review requirements for participating UnitedHealthcare Community Plan of Texas STAR Ki |
| UnitedHealthcare Community Plan | Texas STAR+PLUS | TX | prior auth required | site of care: site of service reviewed | Jan 1, 2015 | Prior authorization requirements for STAR+Plus Effective September 1, 2026 This list contains prior authorization requirements for participating UnitedHealthcare Community Plan STAR+PLUS health care p |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Hawaii (QUEST Integration) | HI | prior auth required | | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Hawaii Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth required | | Jul 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of Kentucky Effective July 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of New York | NY | prior auth required | | Oct 1, 2026 | Prior authorization requirements for UnitedHealthcare Community Plan of New York Effective October 1, 2026 |
| UnitedHealthcare Community Plan | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | | Jan 1, 2015 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |
| UnitedHealthcare Community Plan | Washington Apple Health | WA | prior auth required | | Oct 1, 2026 | Prior authorization requirements for the UnitedHealthcare Community Plan of Washington Effective April 1, 2023 |
| UnitedHealthcare Community Plan | Wisconsin BadgerCare Plus and Medicaid SSI | WI | prior auth required | | Sep 1, 2026 | Prior authorization requirements for Wisconsin Medicaid Effective September 1, 2026 General Information This list contains prior authorization requirements for participating UnitedHealthcare Community |