2021 Prior Authorization Grids

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Medical Prior Authorization Grid | Effective 2/01/2021 (Updated June 2021)
Applies to: B – UFC/ACC, B – UFC/ALTCS, and B – UCA
Pharmacy Prior Authorization Grid | Effective 1/01/2021
Applies: to B – UCA
Pharmacy Prior Authorization Grid | Effective 1/01/2021
Applies to: B – UFC/ACC, B – UFC/ALTCS
Behavioral Health Prior Authorization Grid | Effective 10/01/2021
Applies to: B – UFC/ACC, B – UFC/ALTCS, and B – UCA
ALTCS Prior Authorization Grid | Effective 4/01/2021
Applies to: B – UFC/ALTCS