| 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) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | | Oct 1, 2026 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community MMAI (Medicare-Medicaid Alignment Initiative) | IL | prior auth required | | Jan 1, 2025 | Procedure Code List, Effective 1/1/2025 |
| 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 | 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 | KY | prior auth required | | Jan 1, 2027 | please visit Humana Healthy Horizons in Kentucky Clinical coverage policies. |
| 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 | OK | prior auth required | | Jan 1, 2027 | Humana Healthy Horizons® in Oklahoma 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) |
| 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 | Oak Street Health | All | prior auth required | | | Oak Street Health (Humana): Prior Authorization List (PAL) Codes Under Management |
| 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 | | Jul 1, 2024 | Molina Healthcare of Illinois Codification Grid Q3 2026 |
| 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 Mississippi | Medicaid | MS | prior auth required | | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| 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 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, 2024 | Medicaid Behavioral Health and Medical Prior Authorization (PA) Code Matrix (Texas), 2026-Q3 |
| 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 required | | 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 required | | Feb 1, 2025 | Rocky Mountain Health Plans Medicare Advantage Dual-Special Needs Plans – prior authorization Effective February 1, 2025 |
| UnitedHealthcare Community Plan | Massachusetts OneCare | MA | prior auth under conditions | Prior authorization is required only for prosthetic codes listed with a retail purchase or cumulative rental cost of more than $1,000. | Nov 1, 2025 | Prior authorization requirements for Massachusetts OneCare Effective November 1, 2025 |
| UnitedHealthcare Community Plan | UnitedHealthcare Community Plan of Kentucky | KY | prior auth under conditions | Cost over $500 | 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 | | 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 |