Enable Accessibility
Provider Education & Experience
Provider Portal
Contact Us
About Us
Our Network
Prior Authorizations
Resources
Find a Provider/Rx
News
About Us
Our Network
Prior Authorizations
Resources
Find a Provider/Rx
News
Provider Education & Experience
Provider Portal
Contact Us
Enable Accessibility
Prior Authorizations
Prior Authorization Grids
2018 Prior Authorization Grids
2018 Prior Authorization Grids
Back To Prior Authorization Grids
2025 Prior Authorization Grids
2024 Prior Authorization Grids
2023 Prior Authorization Grids
2022 Prior Authorization Grids
2021 Prior Authorization Grids
2020 Prior Authorization Grids
2019 Prior Authorization Grids
2018 Prior Authorization Grids
2025 Prior Authorization Grids
2024 Prior Authorization Grids
2023 Prior Authorization Grids
2022 Prior Authorization Grids
2021 Prior Authorization Grids
2020 Prior Authorization Grids
2019 Prior Authorization Grids
2018 Prior Authorization Grids
ALTCS Prior Authorization Grid | Effective 10/01/2018
Applies to B – UFC/ALTCS