2023 Prior Authorization Grids

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Behavioral Health Prior Authorization Grid | Effective 4/1/2023
Applies to: B – UFC/ACC, B – UFC/ALTCS
Pharmacy Prior Authorization Grid | Effective 08/01/2023
Applies to: B – UFC/ACC, B – UFC/ALTCS
Part B Step Therapy Guide | Effective 08/01/2023
Applies to: B – UFC/ACC, B – UFC/ALTCS
Medical Prior Authorization Grid | Effective 01/01/2023
Applies to: B – UFC/ACC, B – UFC/ALTCS
ALTCS Services Prior Authorization Grid | Effective 04/01/2023
Applies to: B – UFC/ALTCS