| Arkansas Blue Cross and Blue Shield | Drugs under the medical benefit (not ASE/PSE or FEP, which use EBRx and Prime) | AR | prior auth required | Non-preferred product | Jan 1, 2024 | Medical Benefit Pharmacy Prior Approval List |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Oncology dx: eviCore | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | AZ Blue-administered Medicare Advantage (M2K) | AZ | prior auth required | Non-oncology dx: AZ Blue | Sep 1, 2026 | AZ Blue Medicare Advantage Prior Authorization Requirements Code List (Effective 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Federal Employee Program (FEP) | AZ | prior auth required | | Sep 1, 2026 | Federal Employee Program (FEP) Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Standard PA code list (most commercial plans) | AZ | prior auth under conditions | eviCore-delegated groups, all sites | Sep 1, 2026 | AZ Blue Standard Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | State of Arizona employee group (SYD, S3Z) | AZ | prior auth required | | Sep 1, 2026 | State of Arizona Group Prior Authorization Requirements Code List (09/01/2026) |
| Blue Cross Blue Shield of Arizona (AZ Blue) | Teamsters group (TYW) | AZ | prior auth under conditions | place of service 19, 22; site of care: outpatient hospital | Sep 1, 2026 | Teamsters Group Prior Authorization Requirements Code List (Updated 09/01/2026) |
| Blue Shield of California Promise Health Plan | Promise Health Plan Medi-Cal | CA | prior auth required | | Sep 1, 2026 | Medi-Cal Prior Authorization List |
| Aetna | Medicare Advantage | All | prior auth required | Step therapy applies | Aug 25, 2026 | Aetna Medicare Part B drug list (partbname.xml) |
| Aetna | Medicare Advantage | All | prior auth required | | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Aetna | Commercial | All | prior auth required | | Oct 1, 2026 | Participating provider precertification list for Aetna® |
| Cigna | ACA/IFP | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2019 | Master Precertification List (For Health Care Providers) |
| Cigna | Basic Standard | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2019 | Master Precertification List (For Health Care Providers) |
| Cigna | Complete/PHS+/Preferred | All | prior auth required | May be delegated to eviCore for some clients | Jan 1, 2019 | Master Precertification List (For Health Care Providers) |
| Blue Cross and Blue Shield of Illinois | Blue Cross Community Health Plans (BCCHP), Illinois Medicaid | IL | prior auth required | Carelon-managed | Aug 1, 2025 | Illinois Medicaid Prior Authorization Code List, Effective 10/1/2026 |
| 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) |
| HealthSpring | Medicare Advantage | All | prior auth required | | Jan 1, 2025 | 2026 Q4 Prior Authorization List |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi |
| CarePlus Health Plans | CarePlus Health Plans | FL | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans Prior Authorization and Notification List We have updated our CarePlus Health Plans Prior Authorization and Notification List for CarePlus Medi |
| Humana | Humana D-SNP (FL) | FL | prior auth required | NDC required | Jul 1, 2026 | H1036-280 Humana Fully Integrated Florida prior authorization and notification list |
| Humana | Humana D-SNP (FL) | FL | prior auth required | NDC required | Jul 1, 2026 | H1036-280 Humana Fully Integrated Florida prior authorization and notification list |
| Humana | Humana D-SNP (FL) | FL | prior auth required | NDC required | Jul 1, 2026 | H1036-280 Humana Fully Integrated Florida prior authorization and notification list |
| Humana | Humana D-SNP (IL) | IL | prior auth required | NDC required | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IL) | IL | prior auth required | NDC required | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IL) | IL | prior auth required | NDC required | Jan 1, 2027 | Humana Dual Fully Integrated Illinois prior authorization and notification list |
| Humana | Humana D-SNP (IN) | IN | prior auth required | NDC required | Jan 1, 2027 | Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: |
| Humana | Humana D-SNP (IN) | IN | prior auth required | NDC required | Jan 1, 2027 | Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: |
| Humana | Humana D-SNP (IN) | IN | prior auth required | NDC required | Jan 1, 2027 | Humana PathWays Dual Care (HMO-POS D-SNP) prior authorization and notification list Important notes: |
| Humana | Humana D-SNP (MI) | MI | prior auth required | NDC required | Oct 14, 2026 | Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) |
| Humana | Humana D-SNP (MI) | MI | prior auth required | NDC required | Oct 14, 2026 | Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) |
| Humana | Humana D-SNP (MI) | MI | prior auth required | NDC required | Oct 14, 2026 | Humana Dual Integrated (health maintenance organization Dual Eligible Special Needs Plan (HMO D- SNP) Michigan prior authorization and notification list (PAL) |
| Humana | Humana D-SNP (SC) | SC | prior auth required | NDC required | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (SC) | SC | prior auth required | NDC required | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (SC) | SC | prior auth required | NDC required | Jul 1, 2026 | Humana Dual Integrated South Carolina prior authorization and notification list |
| Humana | Humana D-SNP (VA) | VA | prior auth required | NDC required | Jul 1, 2026 | Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) |
| Humana | Humana D-SNP (VA) | VA | prior auth required | NDC required | Jul 1, 2026 | Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) |
| Humana | Humana D-SNP (VA) | VA | prior auth required | NDC required | Jul 1, 2026 | Prior authorization and notification list Humana Dual Fully Integrated H2875-001 (Virginia) Humana Dual Fully Integrated H2875-003 (Virginia) |
| Humana | Humana Healthy Horizons | FL | prior auth required | NDC required | Jan 1, 2027 | Humana Healthy Horizons in Florida Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | FL | prior auth required | NDC required | Jan 1, 2027 | Humana Healthy Horizons in Florida Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | FL | prior auth required | NDC required | Jan 1, 2027 | Humana Healthy Horizons in Florida Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | KY | prior auth required | NDC required | Oct 7, 2026 | Humana Healthy Horizons in Kentucky Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | KY | prior auth required | NDC required | Oct 7, 2026 | Humana Healthy Horizons in Kentucky Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | KY | prior auth required | NDC required | Oct 7, 2026 | Humana Healthy Horizons in Kentucky Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | LA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | LA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | LA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Louisiana Prior Authorization and Notification List |
| Humana | Humana Healthy Horizons | OH | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Ohio prior authorization and notification List |
| Humana | Humana Healthy Horizons | OH | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Ohio prior authorization and notification List |
| Humana | Humana Healthy Horizons | OH | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Ohio prior authorization and notification List |
| Humana | Humana Healthy Horizons | SC | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in South Carolina prior authorization and notification list |
| Humana | Humana Healthy Horizons | SC | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in South Carolina prior authorization and notification list |
| Humana | Humana Healthy Horizons | SC | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in South Carolina prior authorization and notification list |
| Humana | Humana Healthy Horizons | VA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list |
| Humana | Humana Healthy Horizons | VA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list |
| Humana | Humana Healthy Horizons | VA | prior auth required | NDC required | Oct 14, 2026 | Humana Healthy Horizons in Virginia professionally administered medication prior authorization and notification list |
| Humana | Humana MA and D-SNP | All | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: |
| Humana | Humana MA and D-SNP | All | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: |
| Humana | Humana MA and D-SNP | All | prior auth required | NDC required | Jan 1, 2027 | Medicare Advantage and Dual Eligible Special Needs Plans prior authorization and notification list Important notes: |
| 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 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 Mississippi | Medicaid | MS | prior auth required | cancer dx via Evolent | Jan 1, 2025 | Mississippi Medicaid Prior Auth (PA) Code Matrix and exceptions, effective Q1 2025 |
| Molina Healthcare of Nevada | Medicaid | NV | prior auth required | cancer dx via NCH | 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 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 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 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 Wisconsin | Medicare Advantage | WI | prior auth required | | Oct 1, 2021 | Medicare Prior Auth (PA) Code Matrix (Wisconsin), effective Q4 2021 |