2022 Prior Authorization Grids

Back To Prior Authorization Grids

Behavioral Health Prior Authorization Grid | Effective 4/1/2022
Applies to: B – UFC/ACC, B – UFC/ALTCS
Medical Prior Authorization Grid | Effective 4/1/2022
Applies to: B – UFC/ACC, B – UFC/ALTCS
ALTCS Services Prior Authorization Grid | Effective 4/1/2022
Applies to: B – UFC/ALTCS
Pharmacy Prior Authorization Grid | Effective 9/1/2022
Applies to: B – UFC/ACC, B – UFC/ALTCS
Part B Step Therapy Guide | Effective 9/1/2022
Applies to: B – UFC/ACC, B – UFC/ALTCS