| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List |
| Humana | Humana D-SNP (FL) | FL | prior auth required | | Jan 1, 2027 | 1 *New prior authorization requirement 787403FL0725 FLHMQSREN Humana Dual Fully Integrated Florida Prior Authorization and Notification List |
| Humana | Humana D-SNP (IL) | IL | prior auth required | | Jan 1, 2027 | Humana Dual Fully Integrated Illinois Prior Authorization and Notification List |
| Humana | Humana D-SNP (IN) | IN | prior auth required | | Jan 1, 2027 | *New prior authorization requirement 814403IN0825 H4939_INHN6Z6EN_C Humana PathWays Dual Care (HMO-POS D-SNP) Indiana Prior Authorization and Notification List |
| Humana | Humana D-SNP (MI) | MI | prior auth required | | Jan 1, 2027 | 1 Humana Dual Highly Integrated Michigan Prior Authorization and Notification List |
| Humana | Humana D-SNP (SC) | SC | prior auth required | | Jan 1, 2027 | Humana Dual Highly Integrated South Carolina Prior Authorization and Notification List |
| Humana | Humana D-SNP (VA) | VA | prior auth required | | Jan 1, 2027 | Virginia Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | KY | prior auth required | | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. |
| Humana | Humana MA and D-SNP | All | prior auth required | | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List |
| Humana | Humana Puerto Rico MA and Dual Medicare-Medicaid | PR | prior auth required | | Nov 3, 2025 | Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plans Preauthorization and Notification List Puerto Rico Medicare Advantage and Dual Medicare-Medicaid Plan Preauthorization and Notification |
| Humana | Musculoskeletal | All | prior auth required | | | Humana Prior Authorization List (PAL): Musculoskeletal Services |
| Humana | Musculoskeletal | All | prior auth required | | | Humana Prior Authorization List (PAL): Musculoskeletal Services |
| Humana | Musculoskeletal | All | prior auth required | | | Humana Prior Authorization List (PAL): Musculoskeletal Services |
| Humana | Oak Street Health | All | prior auth required | | | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management |
| 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 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 | 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 Iowa | Medicaid | IA | prior auth required | | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| 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 | 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 | Exchange | TX | prior auth required | | Sep 1, 2019 | Marketplace Prior Authorization (PA) Code Matrix (Texas), effective July 1, 2026 |
| 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 |