2024 Prior Authorization Grids

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Behavioral Health Prior Authorization Grid | Effective 10/1/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
Pharmacy Prior Authorization Grid | Effective 5/15/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
Pharmacy Prior Authorization Grid | Effective 11/01/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
Medical Medication Step Therapy Guide | Effective 5/15/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
Medical Medication Step Therapy Guide | Effective 11/01/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
Medical Prior Authorization Grid | Effective 01/01/2024
Applies to: B – UFC/ACC, B – UFC/ALTCS
ALTCS Services Prior Authorization Grid | Effective 01/01/2024
Applies to: B – UFC/ALTCS