Applications and forms
Medical prior authorization service list (PDF)
Medical injectables (PDF)
Medical benefit prior authorization form (PDF) Medical oncology drugs (effective 1/1/23) Medical non-oncology drugs (effective 10/01/2023) Exception to coverage form for new FDA-approved that have been on the market less than a year. (PDF)
Medicare Part B Prior Authorization list (PDF) Medicare Prior Authorization Review when Absent NCD/LCD (PDF)
Non-covered services (PDF)
Medical management Care management
Radiology policies/NIA Pharmacy PA Mental health Genetic testing Musculoskeletal
Durable medical equipment (PDF) General (PDF) Skilled nursing facility/swing bed (PDF) Mental health (PDF)
Medical policies Drug policies Medical oncology drugs (effective 1/1/23) Medical non-oncology drugs (effective 10/01/2023) ASO prior authorization Clinical guidelines