2025 Prior Authorization Grids

Medical Prior Authorization Grid | Effective 01/23/2025
Applies to: Banner Medicare Advantage Dual HMO D-SNP, Banner Medicare Advantage Prime HMO

Medical Prior Authorization Grid | Effective 01/23/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS

Pharmacy Prior Authorization Grid | Effective 11/01/2024-5/31/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS

Pharmacy Prior Authorization Grid | Effective 06/01/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS

Medical Medication Step Therapy Guide | Effective 11/01/2024-5/31/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS

Medical Medication Step Therapy Guide | Effective 06/01/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS

Behavioral Health Prior Authorization Grid | Effective 03/01/2025
Applies to: B – UFC/ACC, B – UFC/ALTCS