| 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 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 | 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 |
| 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 California | Medicaid | CA | prior auth required | | Apr 1, 2026 | Medicaid Prior Auth (PA) Code Matrix (California), effective Q2 2026 |
| 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 under conditions | no PA with cancer dx | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| Molina Healthcare of Michigan | Medicaid | MI | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | Molina Healthcare of Michigan PA Matrix 2026-Q3 |
| Molina Healthcare of Mississippi | Medicaid | MS | prior auth under conditions | no PA with cancer dx | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of New Mexico | Medicaid | NM | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | New Mexico Medicaid Prior Auth (PA) Code Matrix, effective July 1, 2026 |
| Molina Healthcare of Ohio | Medicaid and MyCare Ohio (MMP) Medicaid | OH | prior auth under conditions | no PA with cancer dx | 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 under conditions | no PA with cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| Molina Healthcare of Ohio | Exchange | OH | prior auth under conditions | no PA with cancer dx | Oct 1, 2023 | Molina Healthcare of Ohio Prior Authorization (PA) Code List, effective 2023-10-01 |
| 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 under conditions | no PA with cancer dx | Jan 1, 2023 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| Molina Healthcare of Texas | Exchange | TX | prior auth required | | Jan 1, 2023 | 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 |
| Passport by Molina Healthcare (Kentucky) | Medicaid | KY | prior auth under conditions | no PA with cancer dx | Jul 1, 2026 | Kentucky Medicaid Prior Auth (PA) Code Matrix and Kentucky PA Code Exceptions, effective Q3 2026 |
| Rocky Mountain Health Plans | Rocky Mountain Medicare Advantage D-SNP | CO | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
| UnitedHealthcare | Preferred Care Network and Preferred Care Partners of Florida | FL | prior auth under conditions | only with dx F64.A, F64.0, F64.1, F64.2, F64.8, F64.9 | Oct 1, 2026 | Prior authorization requirements for Preferred Care Network and Preferred Care Partners of Florida Effective October 1, 2026 |
| UnitedHealthcare | UnitedHealthcare Medicare Advantage, Peoples Health and Dual Complete (D-SNP) | All | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, F64.A | Oct 1, 2026 | UnitedHealthcare® Medicare Advantage/ Peoples Health Plans prior authorization requirements Effective October 1, 2026 |
| UnitedHealthcare Community Plan | Massachusetts OneCare | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts Senior Care Options (SCO) | MA | prior auth under conditions | only with dx F64.0, F64.1, F64.2, F64.8, F64.9, Z87.890 | 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 | 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 | 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 | UnitedHealthcare Connected (Texas MMP) | TX | prior auth required | | Jan 1, 2017 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |