| Blue Shield of California | Blue Shield Medicare | CA | prior auth required | | Sep 1, 2026 | Prior Authorization List for Blue Shield Medicare |
| Blue Shield of California | Blue Shield commercial | CA | prior auth required | | Sep 1, 2026 | Prior Authorization List for Blue Shield |
| Blue Cross and Blue Shield of Texas | Texas PA exemption (gold card), outpatient, fully insured | TX | prior auth required | Gold-card exemption available | Jul 1, 2026 | BCBSTX Outpatient Prior Authorization Exemption Clinical Guidelines (max units, PA exempt date range) |
| 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 (VA) | VA | prior auth required | | Jan 1, 2027 | Virginia Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | IN | prior auth required | | Jan 1, 2027 | 1 Humana Healthy Horizons® in Indiana Preauthorization and Notification List (PAL) for Indiana PathWays for Aging Please note the term prior authorization when used in this communication, is defined a |
| Humana | Humana Healthy Horizons | LA | prior auth required | | Jan 1, 2027 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List To Except where noted via links on the following pages, prior authorization requests for medical services may be initiate |
| Humana | Humana Healthy Horizons | OH | prior auth required | | Jan 1, 2027 | 555201OH0924-B OHHMZG2EN Humana Healthy Horizons® in Ohio Prior Authorization Notification List (PAL) The following preauthorization and notification list |
| Humana | Humana Healthy Horizons | SC | prior auth required | | Jan 1, 2027 | Humana Healthy Horizons in South Carolina Prior authorization and Notification List The following list describes services and medications that are commonly reviewed and may require additional clinical |
| Humana | Humana Healthy Horizons | VA | prior auth required | | Jan 1, 2027 | Humana Healthy Horizons in Virginia Prior Authorization and Notification List (PAL) |
| Molina Complete Care (Virginia) | Medicare-only PA matrix for D-SNP | VA | prior auth under conditions | PA after 4 units | 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 under conditions | PA after 4 units | Jan 1, 2022 | Medicare Prior Auth (PA) Code Matrix (Arizona), effective Q1 2022 |
| Molina Healthcare of California | Medicaid | CA | prior auth required | State exception | 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 Iowa | Medicaid | IA | prior auth required | Prior auth required after initial 4 hours of testing | Jul 1, 2023 | IA Prior Authorization Matrix, effective Q3 2023 |
| 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 | 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 under conditions | PA after 20 hours/encounters | 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 | PA after 20 hours/encounters | 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 | PA after 20 hours/encounters | 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 | Prior Auth required after initial 4 hours of testing per calendar year | 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 |
| Rocky Mountain Health Plans | Northeast Health Partners RAE 2 behavioral health | CO | prior auth required | | Jul 1, 2026 | Behavioral health prior authorization requirements for Northeast Health Partners RAE 2 Medicaid Effective July 1, 2026 This list contains prior authorization requirements for health care professionals |
| Rocky Mountain Health Plans | Rocky Mountain D-SNP behavioral health | CO | prior auth required | | Jul 1, 2025 | Behavioral health prior authorization requirements for Rocky Mountain Medicare Advantage and Dual Special Needs Plans Effective July 1, 2025 This guide provides an overview of the CPT® and HCPCS codes |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans CHP+ behavioral health | CO | prior auth required | | Jul 1, 2026 | Behavioral health prior authorization requirements for Rocky Mountain Health Plans CHP+ Effective July 1, 2026 This list reviews the prior authorization requirements for which Rocky Mountain Health Pl |
| Rocky Mountain Health Plans | Rocky Mountain Health Plans RAE/Prime behavioral health | CO | prior auth required | | Jul 1, 2026 | Behavioral health prior authorization requirements for Rocky Mountain Health Plans RAE/PRIME Medicaid Effective July 1, 2026 This list contains prior authorization requirements for health care profess |
| UnitedHealthcare Community Plan | Texas CHIP | TX | prior auth required | | Oct 1, 2019 | 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 Kids | TX | prior auth required | | Oct 1, 2019 | 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 | | Oct 1, 2019 | 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 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 Connected (Texas MMP) | TX | prior auth required | | Oct 1, 2019 | Prior authorization requirements for UnitedHealthcare Connected (Medicare-Medicaid Plan) Texas Effective November 1, 2025 This list contains prior authorization review requirements for participating U |